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Full text of "The American journal of the medical sciences"





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Property of the 

Lancaster City and County 
Medical Society 






No, 



^x*^*- 



THE 



AMEEICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



EDITED BY 



ISAAC HAYS, M.D., 

SURGEON TO WILLS HOSPITAL, 

PHYSICIAN TO THE PHILADELPHIA ORPHAN ASYLUM, 

MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY, OP THE 

ACADEMY OP NATURAL SCIENCES OP PHILADELPHIA, 

&c. &;c. &C. 



f 



w 



NEW SERIES. 
VOL. vm. 




PHILADELPHIA: 
LEA & BLANC HARD. 

LONDON: 
WILEY & PUTNAM, AND JOHN MILLER 

1844. 



69435 



Entered according to Act of Congress, in the year one thousand eight hundred 
and forty-four, by 

LEA AND BLANCHARD, 

in the Office of the Clerk of the District Court for the Eastern District of Penn- 
sylvania. 



^^ff^X^^^^^U^^\ 




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T. K. & P. G. Collins, Printers. 






TO READERS AND CORRESPONDENTS. 



The communications of Professors J. C. Warren and W. L. Atlee, and of 
Drs. Watson, Tabb, and Hildreth, shall appear in our next No. 

The foilowincr works have been received : — 

Anatomie et Physiologie du Systeme Nerveux de I'homrae et des animaux 
Vertebre; ouvrage contenant des observations pathologiques-relationes au sys- 
teme Nerveux et des experiences sur les animaux des classes superieures; 
Par F. A. Longet, Laureat de I'Institut de France, D. M. P. Prof. d'Anat. et 
de Physiologie, &c. &c. &c. Paris. Fortin, Masson & Co : 1842. 2 vols. 8vo. 
(From the publishers.) 

Traite complet de I'anatomie, de la physiologic et de la pathologie du sys- 
teme nerveux cerebro-spinal. Par M. Foville, Medecin en chef de la Maison 
Toyale de Charenten, &c. &c. &c. Ire. Partie Anatomie avec un atlas de xxiii 
planches. Paris: Fortin, Masson & Co. 1844. (From the publishers.) 

Memoires de la Societe Medicale d'Observation de Paris. Tom. II. Paris: 
Fortin, Masson & Co. 1844.^ (From the publishers.) 

Traite des Phenomenes Electro-Physiologiques des animaux. Par Mat- 
teucci suivi d'etudes anatomiques sur le systeme nerveux et sur I'organe elec- 
trique de la torpille. Par Paul Savi. Paris: Fortin, Masson & Co. 1844. 
(From the publishers.) 

Researches on Operative Midwifery, &c., with Plates. By Fleetwood 
Churchill, M. D., Lecturer on Midwifery, &c. &c. &c. Dublin, 1841. (From 
the author.) 

On the Principal Diseases of Females. By Fleetwood Churchill, M. D., 
Mi R. J. A., Lecturer on Midwifery, with Diseases of Women and Children, 
&c. &c. &c. Second edition. Dublin, 1844. (From the author.) 

General Report of the Royal Hospitals of Bridewell and Bethlem, and of the 
House of Occupations, for the year ending Slst December, 1843. London, 
1844. (From Dr. Webster.) 

Address to the Members of the Massachusetts Medical Society. (From Dr. 
E. .Tarvis.) 

Second Annual Report to the Legislature, under the act of March, 1842, relat- 
ing to the Registry and Returns of Births, Marriages and Deaths in Massachu- 
setts, for the year ending May 1, 1843. By John A. Bolles, Secretary of the 
Commonwealth. Boston, 1843. (From Dr. E. Jarvis.) 

A complete condensed Practical Treatise on Ophthalmic Medicine. By 
Edward Octavius Hocken, M.D., Physician to the Blenheim Surgical Infirm- 
ary and Dispensary, &c. &c. &c. London, 1844. (From the author.) 

The Cyclopedia of Practical Medicine. Edited by Dr. Forbes. Tweedie & 
Conolly. (Revised by Dr. Dunglison.) Parts I, II, III, IV, V, VI, VIL 
Lea & Blanchard, 1844. (From the publishers.) 

Popular Lectures on the Mechanical Nature and Physical Cure of Chronic 
Diseases of the Human Body. By Dr. E. P. Banning. Boston, 1844. (From 
the author.) 

A Practical Treatise on Midwifery. By M. Chailly, M. D. P., Professor of 
Midwifery, &c. &c., illustrated with two hundred and sixteen wood cuts. A 
work adopted by the Royal Council of Public Instruction. Translated from 
the French and edited by Gunning S. Bedford, A. M., M. D., Professor of 
Midwifery and the Diseases of Women and Children in the University of New 
York. New York, 1844. (From the editor.) 



IV ^ TO READERS AND CORRESPONDENTS. 

Transactions of the New York State Medical Society. Vol. vi. Part I. 
Albany, 1844. (From the Society.) 

Pathological Haematology. An Essay on the Blood in Disease. By G. 
Andral, Professor of General Pathology and Therapeutics in the University of 
Paris. Translated from the French by J. F. Meigs, M. D., and Alfred Stille, 
M. D. Philadelphia, Lea ^ Blanchard, 1844. (From the publishers.) 

A Treatise on Operative Surgery ; comprising a description of the various 
processes of the art, including all the new operations; exhibiting the stale of 
Surgical Science in its present advanced condiiion; with eighty plates, contain- 
ing four hundred and eighty-six separate illustrations. By Joseph Pancoast, 
M. D., Professor of General, Descriptive and Surgical Anatomy in Jefferson 
Medical College, &c. &c. &c. Philadelphia, Carey & Hart, for G. N. Loomis, 
1844. (From the publishers.) 

Annual Report of the Inspectors of the Mount Pleasant State Prison, to the 
Honourable the Legislature of the State of New York. 1844. (From Dr. T. 
R. Beck.) 

Fifty-seventh Annual Report of the Regents of the University of the State of 
New York. Albany, 1844. (From Dr. T. R. Beck.) 

Catalogue and Circular of the Albany Medical College. Albany, 1844. 
(From Dr. T. R. Beck.) 

State of the Accounts of the Pennsylvania Hospital. Philadelphia, 1844. 

Report of the Progress of Practical Medicine in the Departments of Mid- 
wifery and the Diseases of Women and Children, during the years 1842-3. By 
Charles West, M. D., Member of the Royal College of Physicians, Physician 
to the Royal Infirmary for Children, &c. &c. &c. (From the author.) 

On the comparative value of the Preparations of Mercury and Iodine in the 
treatment of Syphilis. By Edward 0. Hocken, M.D., &c. &c. (From the 
Ed. Medical and Surgical Journal, No. 159. (From the author.) 

Outlines of Pathology and Practice of Medicine. By William Pulteney 
Alison, M. D., F. R. S., &c. &c. Philadelphia, Lea & Blanchard, 1844. (From 
the publishers.) 

The Practice of Medicine: A General Treatise on Special Pathology and 
Therapeutics. By Robley Dunglison, M. D., Professor of the Institutes of 
Medicine, &c., in Jefferson Medical College. Second edition. Philadelphia, 
Lea & Blanchard, 1844: 2 vols., 8vo. (From the publishers.) 

The Ethics of Medicine. An Anniversary Address, delivered April 3. 1844, 
before the Medico-Chirurgical Society of Louisiana. By Thomas M. Logan, 
M. D. (Published by the Society.) New Orleans, 1844. (From the author.) 

Eleventh Annual Report of the Trustees of the State Lunatic Hospital at Wor- 
cester. (From Dr. E. Jarvis.) 

Annual Report of the Board of Trustees of the Massachusetts General Hos- 
pital for the year 1843. (From Dr. E. Jarvis.) 

Fifteenth Annual Report of the Inspectors of the Eastern State Penitentiary 
of Pennsylvania. Philad. 1844. (From Dr. E. Hartshorne.) 

Thirty-seventh Annual Report of the state of the Asylum for the relief of per- 
sons deprived of the use of their reason. Philad. 1844. (From Dr. C. Evans.) 

Introductory Lecture to the Spring Session of Lectures in Castleton Medical 
College. By Joseph Perkins, A. M., M. D. Albany, 1844. (From the author.) 

Reports of the Inspectors of the Western Penitentiary of Pennsylvania for the 
years 1840, 1841, 1842, and 1843, with the accompanying documents. (From 
Dr. Gazzam.) 

The Principles and Practice of Modern Surgery. By Robert Druitt, Sur- 
geon. From the Third London Edition. Illustrated with one hundred and 
fifty-three Wood Engravings. With Notes and Comments, by Joshua B. 
Flint, M.D.— M.M. S.S., late Professor of Surgery in the Medical Institute of 
Louisville : 8vo. Philadelphia, Lea & Blanchard : 1844, pp. 568. (From the 
publishers.) 

De Prolapsu Funiculi Urabilicalis. J. C. Saxtorph. Hauniae, 1843. (From 
Dr. Otto.) 



TO READERS AND CORRESPONDENTS. V 

De viribns et rationibus maiorura dosiura Calomellis, C. J. E. Hornemann. 
Hauniee, 1839. (From Dr. Otto.) 

De eventu sectionis Caesareas. C. Kayser. Haunia?, 1841. (From Dr. 
Otto.) 

Commentatio de quibusdam Americas Meridianse Medicaraentis parum cognitis. 
C. Otto. Haanise, 1841. (From the author.) 

Darstellung der Verfassung und Einrichtung de Baumwol-Spinnerei-Fabriken 
in Nieder-Oesterreich. Von .1. J. Knolz. (From Dr. Oppenheim.) 

Briefe iiber die zwanzigste versammlung deatscher Naturforscher und Aerzte 
zu Mainz. Von G. L. Dietrich. Landshut, 1842. (From Dr. Oppenheim.) 

Ueber Iritis. Von F. A. Von Ammon. Berlin, 184.3. (From the author.) 

Medicinischer Jahresbericht von Peter-Pauls-Hospitale in St. Petersburg fiir 
das Jahr, 1840 and 1841. St. Petersburg, 1843. (From Dr. Oppenheim.) 

Guy's Hospital Reports. Second series, No. 2. Oct. 1843, and April, 1844. 
(In exchange.) 

London Medical Gazette. Feb., March, April, May, 1844. (In exchange.) 

The Medical Times. March, April, May, 1844. (In exchange.) 

The Dublin Medical Press. March, April, 1844. (In exchange.) 

Provincial Medical Journal. March, April, May, 1844. (In exchange.) 

The British and Foreign Medical Review. April, 1844. (In exchange.) 

The Edinburgh Medical and Surgical Journal. April, 1844. (In exchange.) 

London and Edinburgh Monthly Journal of Medical Science. April, 1844. 
(In exchange.) 

Revue Medicale Francaise et Etrangere. Journal des Progres de la Medecin 
Hippocratique. Par J. B. Cayol, ancien Professeur de Clinique Med. a la 
Faculte de Med. de Paris. Sept., Oct., Nov., Dec, 1843. (In exchange.) 

Annales d'Hygiene Publique et de Medecine Legales. Oct., 1843. (In ex- 
change.) 

Gazette Medicale de Paris. Oct., Nov., Dec, 1843. Jan. 1844, (In ex- 
change.) 

La Lancette Fran§aise, Gazette des Hopitaux Civils et Militaires. Sept., 
Oct., Nov., Dec, 1843. (In exchange.) 

Journal des Connaissances Medico-Chirurgicales. Oct., Nov., Dec, 1843. 
Jan., 1844. (In exchange.) 

Journal des Connaissances Medicales Pratiques et de Pharmacologie. Sept., 
Oct., Nov., Dec, 1843. Jan. 1844. (In exchange.) 

Journal de Medecine et de Chirurgie Pratiques. Oct., Nov., Dec, 1843. 
Jan. 1844 (In exchange.) 

L'Experience, Journal de Medecine et de Chirurgie. Sept., Oct., Nov., Dec, 
1843. Jan. 1844. (In exchange.) 

Annales de Therapeutique Medicale et Chirurgicale et de Toxicologie. April, 
May, June, July, Aug., Sept., Oct., Nov., Dec, 1843. Jan. 1844. (In ex- 
change.) 

Journal de Pharmacie et de Chemie. Oct., Nov., Dec, 1843. (In exchange.) 

Annales Medico-Psychologiques. Journal de 1' Anatomic de la Physiologie et 
de la Pathologic du SystemeNerveux, destine particulierement a recueillier tous 
les documents relatifs a la science des Rapports du Physique et du Moral a la 
pathologic mentale, a la medecine legale des alienes, et a la clinique des maladies 
neiveuses ; par M. M. les docteurs Baillarger, Medecin des alienes a la Salpe- 
triere. Cerise et Longet. Jan. 1844. (In exchange.) 

Bulletin Bibliographique des Sciences Medicales et des Sciences qui s'y rap- 
portent. Nos. 2, 3. 1843. (In exchange.) 

Zeitschrift fiir die gesammte Medicin. Aug., Sept., Oct., Nov., Dec, 1843. 
Jan., Feb., March, April, 1844. (In exchange.) 

Heije's Archief voor Geneeskunde. 1842, 1843. (From Dr. Oppenheim.) 

The Boston Medical and Surgical Journal. April, May, and June, 1844. (In 
exchange.) 

The American Journal of Science and Arts. April, 1844. (In exchange.) 

1* 



VI TO READERS AND CORRESPONDENTS. 

The St. Louis Medical and Surgical Journal. March, April, and May, 1844. 
(In exchange.) 

The Illinois Medical and Surgical Journal. Vol. I. April and May, 1844. 
(In exchange.) 

The Western Lancet. March, April, and May, 1844. (In exchange.) 

The Bulletin of Medical Science. April, May, and June, 1844. (In ex- 
change.) 

The Western Journal of Medicine and Surgery. April, May, 1844. (In ex- 
change.) 

The Select Medical Library, April, 1844, containing Nunneley on Erysipelas. 
(In exchange.) 

The New Orleans Medical Journal, devoted to the cultivation of Medicine and 
the Associate Sciences. May, 1844. (In exchange.) 



Communications intended for publication, and Books for Review, should -be 
sent,/ree of expense, directed to Isaac Hays, Md., Editor of the Amer. Journ. of 
Med. Sci., care of Messrs. Lea and Blanchard, Philadelphia. Parcels directed as 
above, and sent (carriage paid) under cover, to John Miller, Henrietta Street, 
Covent Garden, London, or to Wiley & Putnam, JVew York, or W. D. Ticknor, 
Boston, or M. Hector Bossange, Lib. quai Voltaire, No. 11, Paris, will reach us 
safely. We particularly request the attention of our foreign correspondents 
to the above, as we are often subjected to unnecessary expense for postage and 
carriage. 

All remittances of money, and letters on the business of the Journal, should be 
addressed exclusively to the publishers, Messrs. Lea & Blanchard. 

iJ;7=' The advertisement sheet belongs to the business department of the 
Journal, and all communications for it should be made to the publishers, under 
whose exclusive control it is. 



CONTENTS 

OF THE 

AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 

No. XV, NEW SERIES. 
JULY, 1844. 

ORIGINAL COMMUNICATIONS. 
MEMOIRS AND CASES. 

ART. PAGE 

i. The Influence of Oxygen on the Human System. By D. P. Gardner, 
M. D., Lecturer on Chemistry, New York, &c. No. 1. - - - 13 

II. On Cyanosis, or Morbus Ca^ruleus. By Moreton Stille, M. D. - - 25 

III. Case of Extirpation of a Bilocular Ovarian Cyst by the large Perito- 
neal Section. By Washington L. Atlee, M. D., of Lancaster, Penn., 
Professor of Medical Chemistry in the Medical Department of Pennsyl- 
vania College, Philadelphia. Read before " the Lancaster City and 
County Medical Society," April 17th, 1844. 43 

IV. Surgical Cases and Remarks. By Thomas Wells, M. D., Columbia, 

S. C. (With two wood-cuts.) 69 

Case I. Chronic Empyema — paracentesis — Cavity injected — Cure. - 69 

Case 11. Injury of thigh — rupture of gracilis muscle — extensive effusion — 

incision — Cure. 77 

Case III. Extensive disease of the tibia — removal of nearly one-third of 

the shaft of the bone — the bone reproduced, and limb preserved. - 79 

Case IV. Enormous encysted tumour developed in the upper part of the 

thigh — treated by incision, discutient application, bandages, &c. - 82 

V. On the Treatment of the Inflammatory Affections of Malarious Districts. 

By Wm. M. Boling, M. D., of Montgomery, Alabama. - . . 87 

VI. Case of Osteo-sarcoma of the Lower Jaw — Excision — Cure. By 
Joseph P. Jervey, M. D., of Charleston, S. C. (With a wood-cut.) -Ill 

VII. Case of Craniotomy. By Charles C. Hildreth, M. D., of Zanesville, 
Ohio. 113 

REVIEW. 

VIII. Traite Clinlque et Partique des Maladies des Enfans; par MM. Ril- 
liet et Barthez, Docteurs en Medecine, anciens internes laureats de THo- 
pital des Enfans Malades de Paris, &c. &c. Tomes III. pp. 2375, 8vo. 
Paris, 1843. 

Clinical and Practical Treatise on the Diseases of Children. By MM. Ril- 
liet and Barthez, &c. 117 



Vlll CONTENTS. 



BIBLIOGRAPHICAL NOTICES. 

ART. PAGE 

IX. Anatomie et Physiologie du Systeme Nerveux de I'Homme et des Ani- 
maux Vertebres ; ouvrage conlenant des Observations Pathologiques 
relatives au Systeme Nerveux, et des Experiences snr les Animaux des 
classes siiperieures. Par F. A. Longet, Laureat de I'lnstitut de France, 
(Academie des Sciences ;) Docteur en Medecine de la Faculte de Paris ; 
Professeur d'Anatomie et de Physiologie; Chirurgien de la premiere 
succursale de la Maison Royale de Saint Denis ; Membre de la Societe 
Anatomique. Paris, 1842. 2 vols. 8vo., pp. 942 and 698. 

The Anatomy and Physiology of the Nervous System of Man and of the 
Vertebrated Animals generally; comprising a Series of Pathological 
Observations in relation to the Nervous System, and a detail of Experi- 
ments made upon the higher order of Animals. By F. A. Longet, 
M. D., &c. &c. - - - 161 

X. Traite complet de I'Anatomie, de la Physiologie, et de la Pathologie 
du Systeme IMerveux Cerebro-spinal. Par. M. Foville, Medecin en chef 
dela Maison Royale de la Charenton, &c. &c. Premiere parte. Ana- 
tomie — avec un atlas de xxiii planches. 8vo. pp. 676. Paris, 1844. 

A complete Treatise on the Anatomy, Physiology, and Pathology of the 
Cerebro-spinal Nervous System. By M. Foville, Physician in Chief to 
La Maison Royale de la Charenton, &c. &c. Part 1st. Anatomy — 
with a quarto atlas containing 23 lithographic plates. - - » - 171 

XI. Memoires de la Societe Medicale d'Observation de Paris. Tome deu- 
xieme. Paris, 1844. 

Memoirs of the Medical Society of Observation of Paris. Second volume. 
Paris, 1844: pp. 596. 173 

XII. 1. Eleventh Annual Report of the Trustees (and the Superintendent) 
of the State Lunatic Hospital, at Worcester, (Mass.) December, 1843, 
pp. 109. 

2. Annual Report of the Board of Trustees of the Massachusetts General 
Hospital (and of the Superintendent of the McLean Asylum for the In- 
sane) for the year 1843, pp. 64. 

3. State of the New York Hospital and Blooraingdale Asylum, for the 
year 1843, pp. 28. 

4. The Annual Report of the Physician and Superintendent of the Eastern 
Asylum, in the city of Williamsburg, Virginia, for 1843, pp. 44. 

5. Annual Report of the Managers of the Lunatic Asylum (Kentucky) 
for 1843. 

6. Twenty-seventh Annual Report of the state of the Asylum for the relief 
of persons deprived of the use of their reason. Frankford, 1844, pp. 25. 

7. The Nineteenth Annual Report of the officers of the Retreat for the In- 
sane, at Hartford. 1843, pp. 24. 

8. Sixteenth Annual Report of the President and Directors of the Western 
Lunatic Asylum, to the Legislature of Virginia : with the Report of the 
Superintendent and Physician, for 1844. Staunton, 1843, pp. 41. - - 178 

XIH. A Practical Treatise of Midwifery. By M. Chailly, Doctor of Medi- 
cine, and ex-chief of the Obstetric Clinique of the Faculty of Paris, Pro- 
fessor of Midwifery, Member of the Society of Medical Emulation, &c. 
&c. &c. Illustrated with two hundred and sixteen wood-cuts. A work 
adopted by the Royal Council of Public Instruction. Translated from 
the French, and edited by Gunning S. Bedford, A. M., M. D., Professor 
of Midwifery and the Diseases of Women and Children in the University 
of New York. 8vo. pp. 530. New York, 1844. - - - -183 

XIV. Second Annual Report of the Legislature, under the Act of March, 
1842, relating to the Registry and Returns of Births, Marriages and 
Deaths in Massachusetts. For the year ending May 1st, 1843. By 



CONTENTS. IX 

ART. PAGE 

John A. Bolles, Secretary of the Commonwealth. Boston, 1843 : 86 
pages, 8vo., with additional tables. ___.__. 190 
XV.°Address to the Members of the Massachusetts Medical Society. Bos- 
ton, March 1844. 191 

XVI. The Cyclopedia of Practical Medicine. Edited by John Forbes, 
M. D., F. R. S., Alexander Tweedie, M. D., F. R. S., and John Conolly, 
M. D. Revised, with additions, by Robley Dunglison, M. D. Parts 1, 

2, 3, 4,5, 6 : Philadelphia, Lea and Blanchard, 1844. - - - -194 

XVII. The Practice of Medicine: a Treatise on Special Paiholoo'y and 
Therapeutics. By Robley Dunglison, M. D., Prof. Inst, of Med. &c., in 
Jefferson Med. Col., &c. &c. &c. Second edition, in two volumes. 
Philadelphia: Lea & Blanchard. - 195 

XVIII. Outlines of Pathology and Practice of Medicine. By William 
Pulteney Alison, M. D., F. R. S. E. Fellow and late President of the 
Royal College of Physicians, Edinburgh, and of the Medico-Chirnrgical 
Society, Edinburgh; Honorary Fellow of the King's and Queen's College 
of Physicians of Ireland, and of the Royal Medical Society, Edinburgh ; 
Professor of the Practice of Medicine in the University of Edinburgh, 
and one of the Physicians in ordinary to her Majesty for Scotland. Phi- 
ladelphia: Lea & Blanchard, 1844: pp.424. 195 

XIX. Annales Medico-Psychologiques. Journal de I'Anatomie, de la 
Physiologie et de la Pathologie du Systeme Nerveux. Destine particu- 
lierement arecueillier tous les documents relatifs a la science des Rap- 
ports du Physique et du Moral, a la Pathologie Mentale, a la medicine 
Legale alienes, eta la clinique des maladies nerveuses. Par M. M. les 
docteurs Baillarger, Medecin des alienes a la Salpetriere. Cerise et 
Longet. Paris, Janiver, 1844. 

Medico-Psychologic Annals. A Journal of Anatomy, Physiology, and the 
Pathology of the Nervous System. Particularly devoted to the collec- 
tion of all documents connected with the science of Physical and Moral 
relations, to Mental Pathology, the Medical Jurisprudence of Insanity, 
and Clinics on Diseases of the Nerves. .-_--, 19g 

XX. Pathological Hematology. An Essay on the Blood in Disease. By 
Ct. Andral, Professor of General Pathology and Therapeutics in the 
University of Paris, &c. &c. Translated from the French by J. F. Meigs, 
M. D., and Alfred Stille, M. D. Philadelphia: Lea & Blanchard, 1844, 

pp. 129, 8vo. 197 

XXI. The Principles and Practice of Modern Surgery. By Robert Druitt, 
Surgeon. From the Third London Edition. Illustrated with one hun- 
dred and fifty-three wood engravings. With Notes and Comments, by 
Joshua B. Flint, M. D., M. M. S. S., late Professor of Surgery in the 
Medical Institute of Louisville: 8vo. Philadelphia: Lea & Blanchard, 
1844: pp. 568. 198 

XXII. Report on the Progress of Practical Medicine in the Departments of 
Midwifery, and the Diseases of Women and Children, during the years 
1842-3. By Charles West, M. D., M. R. C. P., Physician to the Royal 
Infirmary for Children ; and Physician-Accoucheur to the Finsbury Dis- 
pensary. London, 1844 : pp. 37. .---.._ 193 

XXUI. Transactions of the New York State Medical Society. Vol. vi. PL 
I. Albany, 1844: pp.78. 8vo. - - 198 

XXIV. Report of the Inspectors of the Western Penitentiary of Pennsyl- 
vania, for the year 1843, with the Accompanying Documents. Alle- 
ghany, 1844 : pp. 16, 8vo. 199 

XXV. Guy's Hospital Reports. Second Series, Nos. 1, 2. April and 
October, 1843. Edited by George Hilaro Barlow, M. A., M. D., Phy- 
sician to Guy's Hospital. Edward Cock, Assistant Surgeon to Guy's 
Hospital. Edmund L. Birkett, M. B., Secretary to the Clinical So- 
ciety. J. H. Browne and A. Poland. London, 1843: pp. 572, 8vo. - 200 



CONTENTS. 



SUMMARY 



IMPROVEMENTS AND DISCOVERIES IN THE 
MEDICAL SCIENCES. 



FOREIGN INTELLIGENCE. 

AnatOxMY and Physiology. 



Process of Secretion. By M. 
Mandl. 201 

Experiments on the action of 
Strychnia on the Nervous Sys- 
tem, and on General and Muscu- 
lar Sensibility. By Dr. Pick- 
ford. 201 



PAGE 

Cryptogamic Plant found grow- 
ing in the Sputa and Lungs of 
a man who laboured under Pneu- 
mothorax. By Dr. Bennett. - 201 

Structure of the Lungs. By 
Mr. Addison. - - - - 202 



Materia Medica and Pharmacy. 



5. New Salt of Mercury and Qui- 
nia. 203 

6. Valerianate of Zinc. - - 203 



7. Chloride of Magnesium. 
Dr. Lebert. - . - 



By 



- 203 



Medical Pathology and Therapeutics and Practical Medicine. 



8. Best mode of administering 
Quinine in Intermittent Fevers. 
By Dr. T. Stratton. 

9. Rarity of Consumption in 
Marshy Countries. By M. Nep- 
ple. _ . _ - - 

10. New Diagnostic signs in Fe- 
brile and other Diseases, which 
presept a Typhoid character, 
By M. Ranque. 

11. Softening of the Spinal Ner- 
vous Substance. — Inordinate 
Venery. — Case of General Pa- 
ralysis. By Sir B. Brodie. 

12. Neuralgia cured by Inocula- 
tion of Salts of Morphia. By 
Dr. Jaques. - - - - 

13. Scirrhus of the Pancreas. By 
Dr. Battersby. 

14. Scirrhous Tumour in Spinal 
Marrow. By M. Bouillaud. - 207 

15. Elephantiasis cured by Guaiac 
and Iodine. By M. Cazenave. 208 

16. Contraction of the foramen 
lacerum posterius, in maniacs 
and suicides. By Dr. Kasloff. 208 



203 



204 



- 204 



205 



206 



- 206 



17. Antipsoric remedies. - - 209 

18. Treatment of Scald Head. - 209 

19. Nervous Tremor in Children. 

By Dr. P. H. Green. - - 210 

20. Large Doses of Nitrate of 
Potass. By H. Bennet. - 210 

21. Sea-side Air as a Remedial 
Agent. By M. Guastalla. - 211 

22. Successful Treatment of Ova- 
rian Dropsy without the Abdo- 
minal Section. By J. B. Brown. 212 

23. Pathological and histological 
researches on the inflammation 
of the nervous centres. By Dr. 

J. H. Bennett. - - - 213 

24. Inoculation of Veratria in 
Neuralgia. By M. Lafargue. - 216 

25. Nux Vomica in Neuralgia. 

By M. Roclants. - - - 216 

26. Belladonna in Dvsmenorrhcea. 

By Dr. G. Bird. " - - - 216 

27. Nitrate of Potass in Spasmo- 
dic Asthma. By Dr. Frisi. - 217 

28. Continued Inflammatory Af- 
fections modified by Marsh 
Miasmata. By M. Guislain. - 217 



CONTENTS. 



XI 



PAGE 

29. Alcoholic Lotion in Phthisis 
Pulmonalis. By Dr. Marshall 
Hall. 218 



30. Epidemic Fever lately preva- 
lent in Scotland. By Dr. Cor- 
mack. 219 



Surgical Pathology and Therapeutics and Operative Surgery. 



30. Trousseau on the Prognosis 

of Tracheotomy in Croup. - 226 

31. Tenotomy — its abuse, and the 
results. By M. Malgaigne. - 227 

32. Ununited Fracture of the fore- 
arm successfully treated by se- 
ton. By Dr. Houston. - - 229 

33. Aneurism of the External 
Iliac Artery — Ligature of the 
Common Iliac. By Richard 
Hey, Esq. - - - - 230 

34. Removal of a knife-blade from 
betvi^een the Trachea and right 
Carotid Artery. By R. T. 
Hunt, Esq. - - - - 233 

35. Intra-capsular Fracture of the 
neck of the Thigh-Bone. By 
Mr. Williams. - - - 234 

36. Process of reparation of frac- 
tured bone. By Mr. Williams. 236 

37. Reproduction of Bone in Ne- 
crosis. By Prof. Syme. - - 238 

38. Necrosis. By Dr. J. A. Lav^r- 
rie. 212 

89. Expediency of operating in 
Cancerous Affections. By M. 
Leroy d'Etioles. - - - 244 

40. Description of a peculiar form 
of Ulceration to which Cica- 
trices are liable. By Mr. Ro- 
bert Smith. - - . - 244 

41. Comminuted fracture of the 
base of the Cranium produced 
by a fall on the feet. By M. 
Robert. 246 

42. Polypous tumour of the Blad- 
der removed by lithontriptic in- 
struments. By M. Vache. - 246 



43. Foreign bodies in the external 
Auditory Canal. By M. Mar- 
chal. 247 

44. Fractured Pelvis, with lacera- 
tion of the Bladder. By M. 
Hall, Esq. - - -' - 248 

45. Cure of Naevi Materni by in- 
oculating with Croton Oil. By 

M. Lafargue. - - - - 248 

46. Extirpation of the Astragalus. 

By M. Rognetta. - - - 249 

47. Treatment of obstinate Stric- 
tures of the Urethra. By Prof. 
Syme. 249 

48. Fracture of the Malleoli. By 

M. Berard. - - - - 250 

49. Berthold's method of arresting 
Haemorrhage from Leech-bites. 250 

50. Lithontriptic Remedies. By 

M. Bouchardat. - - - 250 

51. Removal of a diseased Ova- 
rium terminating fatally on the 
seventh day. By T. M. Green- 
how, Esq. - - - - 251 

52. Case of alarming Syncope, 
from the admission of air into a 
vein during an amputation of 
the shoulder-joint. By B. B. 
Cooper, Esq. - . - - 252 

53. Dissecting Aneurism of the 
Ascending Aorta bursting into 

the Pericardium. By Dr. Lees. 253 

54. Diffuse Cellular Inflamma- 
tion following Vaccination. - 253 

55. Ununited fracture treated by 
acupuncturation. - . - 254 



Ophthalmology. 



56. Chloride of Sodium in dis- 
eases of the Eye. By M. Ta- 
vignot. . - _ - - 254 

57. Cyanide of Zinc in Ulcers 



and Opacities of the Cornea. 
By M. Cabrier. - - 255 

58. Conical Cornea. By Dr. 
James H. Pickford. - - - 255 



Midwifery. 



69. Signs of Pregnancy. - - 255 

60. Watery discharge from the 

Vagina during Pregnancy. By 

M. Chailly. - - - - 257 



61. Ulceration of the Cervix Ute- 
ri. By Dr. Cortilhes. - - 256 

62. Pelvis deformed by Osteoma- 
lacia. By Dr. Spengel. - - 256 



Xll 



CONTENTS. 



63. Malposition of the Uterus as 
an impediment to labour. By 
Dr. Perfetti. - - - - 257 

64. Rupture of the Uterus termi- 
nating favourably. - - - 257 

65. Turnino; in arm presentations. 

By Dr. Hutter. . - - 258 

66. Partus siccus. By M. Mat- 



PAGE 

thysen. 258 

67. Abuse of Obstetric Manoeu- 
vres. By MM. Pereira and 
Lasserre. . - _ _ 259 

68. New Perforator. By Dr. Smith. 259 

69. Complete Congenital Inver- 
sion of the Uterus. By M. W il- 
liaume. 259 



Medical Jurisprudence and Toxicology. 



70. Death from Corrosive Subli- 
mate applied to an Excoriated 
surface. ----- 259 

71. Diseases of the Uterus compa- 
tible with Pregnancy. - - 260 

72. Action of Alcohol and Ether 

on the Animal System. - - 260 

73. Poisoning of children by co- 
loured confectionary and paints. 

By Dr. Beer. - - - - 261 

74. Toxicological experiment with 
Nitrate of Potash. By MM. 
Mojonand Rognetta. - - 262 

75. On poisoning by Copper. By 
MM. Danger and Flandin. - 262 



76. Medico-legal observations on 
Foot-Prints. By M. Mascart. - 263 

77. On Starvation. By M. Chossat. 264 

78. Sudden death from a Mecha- 
nical Cause. - - - - 265 

79. Corpora Lutea. By M. Raci- 
borski. ----- 266 

80. Medico-legal inquiry into the 
Diagnostic character of Ecchy- 
mosis. By Dr. Henry Bayard. 266 

81. Poisoning by Lead. By MM. 
Flandin and Danger. - -267 

82. Trial for Infanticide. - - 267 

83. The Queen y. Trilloe— Infanti- 

cide. 268 



American Intelligence. 



Case of suspected Infanticide. 
By J. W. Thompson. - - 269 

Angular Anchylosis of the Knee- 
Joint successfully treated by 
Dr. J. R. Barton's Method. By 
Dr. Piatt Burr. - - - 270 



Self-propellingpower of the Blood. 
By Dr. Horace Green. - - 273 

Epidemic Erysipelas. By Dr. D. 
Meeker. 273 

University of Penn. Med. De- 
partment. - - - - 275 



% 



THE 

AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



JULY, 1844. 



Art. L — 77^6 Influence of Oxygen on the Human System, By D. P. 
Gardner, M. D., Lecturer on Chemistry, New York, &c. No. 1. 

In this paper I propose to consider the influence of oxygen gas on the 
changes natural to the human body, and in future communications, the re- 
sults of those changes. 

1. The discovery of Dr. Scherer, that the azotized proximate principles 
of plants and animals are identical, is the most important fact in physiology. 
The processes of digestion and nutrition hang upon it. But it has not only 
simplified our doctrines in regard to these two important functions, but also 
offers a solution of the still more recondite subject of the metamorphosis of 
tissues. 

From the remotest antiquity, it has been asserted that the being of to-day 
is altogether distinct from the individual of twenty years back. Nutrition 
and repair have been abundantly investigated, but the waste of tissue, mus- 
cles, and glands has been neglected as beyond our reach. That constant 
death of parts which maintains the energy of the whole, has been too unpro- 
mising or humiliating a subject for physiologists. The dogma of BufFon, so 
grossly misrepresented and little understood, that the larger animals are 
accretions of the lower, is again appearing in a more philosophical dress to 
throw light upon the functions of the animal frame. Each molecule of the 
body, endowed with its proper life, passes through a cycle of existence 
without drawing with it the destruction of the machine of which it is an 
integrant — nay, further; that machine is endowed with new attributes by 
the arrangement of its minor parts. So a single cell in plants, (Chlorococ- 
cum vulgara,) is capable of inhaling gas and fluid, of decomposing car- 
bonic acid in the sun's light, and forming chlorophyl, and starch and albu- 
No. XV.— July, 1844. 2 



14 Gardner on the Influence of Oxygen. U^^Y 

men, but it has not all the properties of united cells; it cannot lay down an 
enduring trunk. 

2. The analysis of vegetable fibrine from wheat, and fibrine of blood gave 
Scherer 



(C) Carbon== 54-603 and 54-454 

(H) Hydrogen= 7-302 and 7*069 

(N) Nitrogen== 15-809 and 15-762 

(O) Oxygen: 

(S) ~ ■ 

(P) Phosphc 



Oxygenss"^ 

Sulphur= C22'285 and 22-715. 
osphorus= J 



Numbers which, those familiar with the results of organic analysis will per- 
ceive, indicate perfect similarity of composition* These numbers have been 
reproduced in the researches of Mulder, Boussingault, Varentrap, Will, and 
Jones. It is not true of fibrine only, but the albumen and casein of ani- 
mals and vegetables are identical. But of the two kingdoms, vegetables only 
possess the property of forming out of inorganic matter, such important 
substances. This function of plants upon which animal existence depends, 
is in its turn dependent upon the action of the sun's beams. By their 
quickening influence the frail cellules of an humble weed can destroy the 
chemical affinities of the atoms of carbonic acid, which no galvanic battery 
can effect, and uniting the carbon with water, lay the foundation of these 
nutritious bodies. Some fungi are, indeed, eminently nutritious, although 
growing without light, and beneath the surface of the soil, as the truffle 
( Tuher cibarium), but these are secondary organizations, depending upon 
the presence of organic matter in the earth — the destroyers rather than the 
producers of vegetable principles. 

3. The animal machine being incapable of forming fibrine, depends for 
its supply upon plants, and by their ingestion it enters the stomach. Its fate 
therein cannot be discovered from all the works on physiology previous to 
the time of Scherer. So sublime did the mystery of digestion appear, that 
those medical men who have not kept pace with the advance of chemical 
knowledge, can hardly be persuaded that it is no more than a case of solu- 
tion. Fibrine digested, which they would have termed fibrine vitalized, 
animalized, chymified, made fit for the nutrition of human beings, is, indeed, 
in our day no more than ^6rme dissolved. 

By what route we care not, by lacteal or absorbent, it reaches the blood, 
and there Mulder and Scherer prove that it is no more than the identical 
fibrine which we trace in a vegetable juice, or the seeds of the cerealia. 

4. Passing with the current of blood along the circulation, ever ready to 
put on the insoluble form as soon as the chemical requisites to its solubility 
are disturbed, each atom ultimately reaches its place of destination in the 
system. Imprisoned in a capillary, which allows no further progress to the 
denser parts of the blood, one principal condition of the soluble state, 
motion, is arrested, and fibrine reaches its appointed station to form one 
monas of a complex animal. Nutrition is no more, in this case, than precipi- 



1844.] Gardner on the Jnjluence of Oxygen. 15 

tation, for Playfair and Boeckmann show that the composition of blood and 
the bodies produced therefrom are similar. 

But the position occupied by the newly added molecule is not fortuitous 
— certain forces having guided its career, and they continue to control its 
destiny. These are nervous power and vitality, or that collection of actions 
which physiologists are pleased to call vital, because unable to separate into 
their components. 

5. The place of deposit, wherever it may be, forms part of a perishable 
tissue — the fibrine becomes subject to the law of the structure. As an inde- 
pendent body, it might have retained its form for ever if removed from the 
agency of moisture and oxygen — or it might have experienced decomposition 
in a few minutes. But its fate is now determined by the necessities of the 
system — this condition remaining, however, that in its complete decay the 
same agents are required and the same products generated. 

6. Fibrine decaying in atmospheric air is surrounded with an abundance 
of oxygen gas and moisture; its resulting products are dependent upon these 
conditions. To place the study of this decomposition in a clear light, I 
shall adopt the atomic constitution of fibrine — Carbon 800, Hydrogen 620, 
Nitrogen 100, Oxygen 240, Phosphorus 1, Sulphur 2, with 0*77 per cent, 
of sulphates and phosphates of lime and magnesia. (Kane.) Under the 
freest supply of oxygen, and in circumstances producing slow decay, all the 
carbon would form carbonic acid, all the nitrogen would unite with hydrogen 
to form ammonia, and the hydrogen in excess, would form water. 

Thus, the atom of fibrine, omitting the sulphur, phosphorus, and saline 
matters, would be resolved into 

100 Ammoma=Nl00+H300 
320 Water = . H320+ O320 

800 Carb. acid = . . Ol600-fC800 

N100+H620+O1920+C800 
and for the change 1680 atoms of oxygen are required more than the fibrine 
contains. This perfect eremacausis would, however, occupy much time, 
and requires a slowness of decay, foreign to azotized matter. The truth is, 
that although the preceding products would be formed, if the conditions were 
maintained — yet in the destruction of such bodies the decomposing forces 
are of too active a nature to give time for the amount of oxygen necessary 
to become absorbed, and new but feebler affinities between carbon, nitrogen, 
and hydrogen come into operation. 

If the fibrine decays under the influence of fermentation, which is an 
active process, the compounds of carbon, hydrogen, and nitrogen, are pro- 
duced much more freely. Cyanogen, carburetted, sulphuretted, phosphu- 
retted hydrogen make their appearance as well as ammonia, water and 
carbonic acid — not in virtue of a specific operation, but because the ratio 
between the rapidity of decay and absorption of oxygen is altered. Just as 
the difficulty of procuring oxygen increases, the production of hydrogen 



16 Gardner on the Influence of Oxygen. [July 

compounds increases, and in those situations where it cannot be absorbed, 
hydrogen compounds only are formed. 

It is this law of nature which has secured to our race the invaluable 
mineral coal. If the vegetable matter from which it has been produced, had 
been abundantly supplied with oxygen, during decay, every atom of carbon 
would have become carbonic acid. But as soon as the atmosphere was 
excluded, all change ceased with the last portions of hydro-carbon formed, 
leaving nearly pure carbon in anthracite. 

7. In the human body, the atom of fibrine, now a molecule in a muscle 
or other organ, suffers death or decay under similar laws. If we turn our 
attention to the ejected products of animals we discover in health an entire 
absence of compounds of hydrogen with carbon, sulphur and phosphorus — 
these bodies I have said mark the want of oxygen, and are the result" of 
rapid decay or fermentation. The living body does not, therefore, in reject- 
ing its effete parts adopt under normal circumstances a fermentative process. 
Neither does it proceed by a perfect oxidation or eremacausis, for we are 
aware of the generation of compounds of nitrogen with carbon. What then 
is the character of the change? 

8. We can obtain a knowledge of it only by considering the products 
resulting. In the discussion of extra-animal decay, the character of the 
decomposition is known by studying the nature of the bodies generated; this 
is also the method in investigating the ultimate metamorphosis of tissues. 

All the normal constituents of the animal frame, may be classed under the 
distinct heads of fibrine, or protein compounds and fats. We may simplify 
our discussion without the remotest shadow of error, by leaving the latter 
bodies out of view, and regarding only the protein class. Again, we may 
confine ourselves to fibrine as a representative of the whole class, and by 
determining its changes, argue fully and correctly to that of every portion of 
the frame. Omitting partial transformations into chondrine, hair, gelatine, 
arterial membrane and secretions so ingeniously discussed by Liebig, I will 
proceed at once to the perfect metamorphosis of fibrine into effete matter. 

9. The excreting organs, whereby the products of decay are thrown from 
the system, are the kidneys, lungs, skin and cutaneous glands. They are 
not to be confounded with the secreting glands, the liver, spleen, testes, 
parotids, thyroids, salivary, pancreas, mammae, mucous exhalents, &c. In 
which list I have included several structures whose office is unknown, but it 
is certain from their situation that they are not excretors. The liver, pancreas, 
and salivary glands have thus been considered by some, but improperly, for 
the saliva is an important adjunct to digestion ; the liver and pancreas, by 
throwing their secretions into the unabsorbed chyle, are evidently intended to 
alter the form of substances which have passed through their structure, and 
fit them for a return into the animal economy. 

Nor is the discussion affected by our ignorance of the office of many 
glands. The constitution of expired air is no matter for cavil; the composi- 



1844.] Gardner on the Influence of Oxygen, 17 

tion of urine, and the character of cutaneous excretions are known, and this 
knowledge is sufficient in itself to furnish us with the history of every par- 
ticle of fibrine that suffers decay. 

10. Searching in the urine for some of the products of decay, we learn 
that principally azotized and saline matters are drained off from the system 
by the kidneys ; — those azotized bodies which have reached a state of meta- 
morphosis that not only unfits them to remain in the tissues of the body, 
but renders them injurious to health. They must not be confounded with 
such fluids as have only reached a partial change, as bile, (C37, H66, N5, 
022,) and contain nitrogen, and are subject to further decay, before thrown 
out of the system as effete. 

11. The exact nature of the urinous azotized matters, will be seen in the 
accompanying analysis of urine by Berzelius [Chemie, t. vii. p. 392). 

Water 933-00 

Urea 30-10 

Uric acid _----- l-QQ 

Lactic acid and lactate of «m//ioma - - - 17-14 

Mucus ------- 0-32 

Sulphate of Potash ----- 3.71 

Sulphate of Soda ----- 3-16 

Phosphate of Soda ----- 2-94 

Biphosphate of ammoma - - - - - i-es 

Chloride of Sodium ----- 4-45 

Muriate of ammonia ----- 1.50 

Phosphate of lime and magnesia - - - 1-00 

Silica ------- 0-03 



1000-00 



Of the above substances those in italics contain nitrogen. It is worth 
while to consider the composition of these bodies with regard to the other 
elementary constituents. 

Urea consists of N2-|-C 3+02-|-H4 

Uric acid N4-|-C10+O6+H4 

Ammonia Nl ' . . H3 



N7. C12. 08. Hll 



As there are 100 atoms of nitrogen in the formula of fibrine (6), we may 
elevate the nitrogen in the above sum to that number, preserving the form in 
regard to other elements — the process gives nearly NlOO, C171, 0114, 
Hi 57. This calculation is based on the supposition that the quantities of 
the azotized bodies in urine, are in proportion to their atomic weights — such, 
indeed, is not the case, but the proportion of nitrogen is higher, for of the 
substances enumerated, urea and ammonia constitute nearly the whole, and 
the former contains little carbon, whilst ammonia is without any. 

If we contrast the ratio of the elements to each other, in the table, with 

, 2* 



18 Gardner on the Influence of Oxygen. [July 

the composition of fibrine, we cannot fail to be struck with the large amount 
of nitrogen in comparison to the carbon ; whereas in fibrine they are as 1 to 
8 ; in urea they become as 1 to 1 ; in uric acid as 2 to 5, and in ammonia the 
carbon is absent. These proportions will not be lost, whatever be the rela- 
tive amount of the different urinous compounds. 

So far, then, urine is a much more azotized product than fibrine, and on the 
ground that it results from the decay of the latter, a large quantity of carbon 
is unaccounted for. 

12. If the water of urine be taken into the account, as it should be, an 
additional amount of oxygen and hydrogen are separated from the elements 
of fibrine. What the exact amount of water produced by the combination 
of its elements derived from decaying fibrine may be, is uncertain, for water 
drank by the individual escapes by the kidneys also. This much is, how- 
ever, certain, that just in proportion as the oxygen and hydrogen are sepa- 
rated from the components of fibrine, the excess of unappropriated carbon 
increases. 

13. Nor can we escape the conviction that the kidneys are not destined to 
separate this element by discovering the presence of lactic acid (C6+H44- 
04) and lactate of ammonia in urine. Lactic acid by the formula contains I5 
times as much carbon as oxygen, but in fibrine the ratio is as 10 to 3; if, 
therefore, a sufiicient quantity of lactic acid were present, to consume all the 
oxygen of fibrine, 440 atoms of carbon would be still ununited. This acid is 
by far the most highly carbonized constituent of urine. But as there should 
be no doubt left on the mind, as to the oflfice of the urinous excrement, it is 
proper to observe that lactic acid is not a product of the decay of fibrine. 
Purely carnivorous animals eject uric acid principally, serpents only urate of 
ammonia. The presence of lactates arises from the decay of bodies of the 
starch family remotely, or of the oleaginous family approximately. 

14. There remain the saline matters of urine; phosphate of lime and 
magnesia are proper to fibrine. Phosphate of ammonia is generated by the 
oxidation of the atom of phosphorus of fibrine, and the subsequent union of 
phosphoric acid with ammonia of the decaying matter. Part of the sulphuric 
acid is also the result of the oxidation of the two atoms of sulphur. The 
remaining saline matters are derived from other proximate substances, and 
from salts taken with food. 

The presence of mucus in minute quantity is to eff'ect a further decay of 
urea and uric acid. These substances, when chemically pure, are stable, but 
in the presence of putrefactive agents and oxygen, are resolved into ammonia 
and carbonic acid. 

15. Upon a thorough investigation of the history of each constituent of 
urine, we are still left with a large quantity of carbon after the separation 
of every other element. It is unnecessary to trace the separation of the 
hydrogen; for in all the foregoing products of decay, urea, uric acid, am- 
monia, and water, it is present in high proportion. 



1844.] GsLYdner on the Influence of Oxygen. 19 

16. Perspiration is another form of excretion by which a part of the pro- 
ducts of decay leaves the body. It usually puts on the form of vapour in 
passing from the skin, but when exhaled in large quantities, or in an atmo- 
sphere, with a dew point approaching 90° F., it becomes fluid. In both 
conditions, as insensible perspiration or sweat, it has been chemically exa- 
mined ; — the former by Thenard and Anselmino, the latter by Berzelius and 
Anselmino. 

17. Perspiration consists of water holding in suspension saline matters, a 
little animal matter, and carbonic acid. Some of these substances are vola- 
tile, others fixed. As long as insensible vapour only passes, the volatile 
portions escape from the skin, but leave behind a pellicle of saline matter, 
which forms the scurf of persons negligent of cleanliness. An accumulation 
takes place, especially in the armpit and groin, from the activity of the 
cutaneous glands in those regions of the body. In sweat the fixed salts 
flow off in solution. 

18. From the examination of Anselmino, reviewed by Berzelius, we learn 
that 100 parts of sweat contain 0*5 to 1*25 per cent, of substances not vola- 
tilized by a water-bath. This great difference depends upon the quantities 
of water drank. Of the solid matter 22.9 per cent, was indestructible at a 
red heat — making 0.114 to 0.286 per cent, of saline matter in sweat. The 
salts are carbonate, sulphate and phosphate of soda, with traces of similar 
potash salts, chloride of sodium, carbonate and phosphate of lime, and a 
trace of oxide of iron. The carbonates of this list are the remains of 
incinerated lactates. 

Among the volatile substances are lactate of ammonia, and an oil possess- 
ing the peculiar odour of the animal. 

Carbonic acid, in a free state, was found in minute quantity by Anselmino; 
Collard de Martigny subsequently discovered nitrogen and hydrogen, but in 
uncertain quantities. The nitrogen has been traced by Liebig to atmospheric 
air taken into the stomach with saliva. It is apparent that where large quan- 
tities of water are drank, the nitrogen and carbonic acid must escape through 
the skin and lungs. Those who visit sulphur springs are aware of the exha- 
lation of sulphuretted hydrogen by the epidermis. These minute quantities 
of gas are not, however, the product of decaying fibrine; for, with the 
exception of water, carbonic acid, and ammonia, the results of its metamor- 
phosis in the system are dissimilar from the products of putrefaction. Both 
urine and perspiration are thrown out of the body with a portion of animal 
matter (mucus), that the final steps of decomposition may be accomplished 
out of the frame. Food, especially that which has commenced to ferment 
or is very prone to change, may liberate gas in the intestinal canal, but this 
has no connection with the metamorphosis of tissues. 

The principal constituent of perspiration is water; no doubt a portion of it 
is drawn from the oxidation of the hydrogen of fibrine, but the greater part 
must be derived from fluid taken into the stomach. 



20 Gardner on the Influence of Oxygen. U^^Y 

Little of the surplus carbon is separated; for, although carbonic acid is a 
constituent of its excretion, and oxygen may be absorbed by the skin, both 
these actions take place to so limited an extent that it has hitherto been con- 
sidered too unimportant to be measured. 

19. It may be proper, before entering on the study of the excretion of the 
lungs, to make some remarks on the mucous membrane of the intestinal and 
urinary apparatus. These have been regarded as the internal skin by many 
physiologists. If such be the case, should we not look upon it as an 
excreting surface, and enumerate its products with those of the kidneys and 
lungs? But that this is not incumbent upon us will appear from an exami- 
nation of the matters thrown out by these mucous membranes — not where 
they are full of glands — but in the most simple state, as in the male pelvis. 
If any notable excretion were thrown off the mucous membrane of the 
urinary system, it would be found in urine. Yet, upon examining that fluid, 
we find only 0*032 per cent, of mucus which has not been derived from the 
kidneys. The office of the mucus has been explained; it is not an excretion, 
but secretion. 

It may be imagined that, notwithstanding the absence of excretion in the 
urinary mucous membrane, the quantities of mucus, or fluids evaporating 
from other portions of the tissue, may be considered excrementitious. This 
speculation can be readily disproved. If the lining membrane of the intes- 
tinal canal throws off any quantity of fluid, it cannot be in the form of 
vapour, but as liquid, inasmuch as the perfect saturation of the gases con- 
tained in the canal renders the process of vaporization impossible. The 
hypothetical fluid produced in the upper parts of the tube, as the oesophagus, 
running downwards into the stomach, would be absorbed by the spongy 
tissue of that organ in the same way as water. But the absorption of excre- 
tions is unnatural, and contrary to the laws of the organization. With 
respect to the fluid excreted according to this hypothesis in the small intes- 
tines and colon, omitting the certainty of absorption, unless produced in 
immense quantities, it is evident that in a state of health the stools containing 
so much fluid should be watery ! How certainly absorption of liquids takes 
place may be gathered from the well known facts, that persons sufliering 
from constipation, eject indurated fasces; and injections of soups, &c. into 
the rectum, have served to maintain life in cases of lock-jaw, &c. for weeks. 

But if the excretion of a quantity of fluid were a function of the mucous 
membrane, what fate would await the lungs of persons resident in moist 
tropical countries? Vapour of water exists in expired air, but it is not 
necessarily an excretion of the mucous membrane. The amount of vapour 
derived from the lungs, is direcfly as the drying power of the inspired air, 
which proves it to be no more than an exhalation of moisture produced on 
mechanical principles. Thus if the dew point of inspired air be 98° F., 
the passage of vapour from the surface of the mucous membranes becomes 
nothing. Or, in other words, if we allow that the secretion of fluid is a 



X,844.] Gardner on the Influence of Oxygen. 21 

function of the mucous membrane, we must likewise admit that in health the 
action may be suspended for months without any apparent disturbance. This 
amounts to an absurdity. Another consequence, no less unnatural, attends 
the assertion that mucous textures excrete a fluid ; if the function existed, a 
dew point of 98° F. would not arrest it; how is it with the epidermis, under 
that atmospheric condition, perspiration ceases, but copious and compensating 
sweat is produced? So in the lungs, sweat or fluid should be formed sufl[i- 
cient to counteract the pressure of the dew point. Does . any one believe 
that it is so produced? 

The halitus of mucous membranes, and the moisture of expired air, are, 
therefore, not excretions, but owe their origin to mechanical causes. 

20. If we turn our attention to the solid dejections, we find no evidence 
of intestinal excretion. The solid itself consists of those portions of food 
which are insoluble in chyle, in excess, or innutritions, and therefore not 
appropriated by the system— we find no mucous excretion. It is not in the 
excrement of an over-fed luxurious gourmand we are to expect this result, 
for in such cases an irritation of the lininoj membrane of the larojer intestines 
may cause them to throw out an abundance of mucus. But turning to the 
lower animals, let us examine the character of the faeces of a healthy dog fed 
on meat and bone — it is well known to consist of a white friable substance 
called album graecum by the older pharmacopolists, and yielding on analysis 
scarcely any thing but the inorganic matter of bones, (phosphate of lime,) 
which is insoluble in chyle. In the case of carnivorous birds, also, we find 
nothing but the urate of ammonia, with inorganic matters as excrement, a 
trace of mucus suflacient to produce decay, being added as in the case of 
urine. 

21. These facts are of deep interest to physiology, not only as proving 
that there is no such thing as mucous excretion, but also in their bearing on 
the important question of the office of bile, which is still considered an 
excretion by medical men. On this subject 1 may now pronounce a decided 
opinion, that bile is not an excretion, or in any way concerned with the ulti- 
mate decay of fibrine. The proof is found in its entire absence in the pre- 
ceding cases; but in addition to these, it was my misfortune, some years 
since, to lose a friend by death, whose ductus communis choledochus had 
been obliterated by the passage of biliary calculi eight months before his 
decease. During the whole of this time no bilious secretion was thrown 
into the bowels, and yet he enjoyed a tolerable amount of health. The 
further history of the case I will communicate in this journal on another 
occasion. 

It is not my object to assert that bile may not be found in any specimen of 
excrement. Berzelius gives 0-9 per cent, of it in a specimen of human 
faeces examined by him. But its presence indicates that the quantity formed 
by the liver is too great for re-absorption, or that some other disturbing cause 



22 Gardner on the Influence of Oxygen, [July 

is in action ; and considering the great irregularities of men in taking food, 
this is probably a frequent case. 

22. There remains but the pulmonary excretion to carry off the surplus 
carbon left from the decay of fibrine, (15). To this office it is destined. 
The carbon has, however, to be converted into carbonic acid to render its 
escape practicable. Hence the absorption of oxygen from the external 
world becomes necessary. In addition to carbonic acid, expired air contains 
a varying quantity of vapour of water, and sometimes a minute increase of 
nitrogen. Of the former I have spoken already ; the latter derives its origin 
from air taken into the stomach with saliva or water, and is not a product of 
decay. 

The lungs are at once destined to excrete carbon and absorb oxygen gas 
— but the union of these elements to form carbonic acid does not take place 
to any great extent in the pulmonary apparatus, but in numerous points in 
every part of the body where fibrine and other animal bodies are undergoing 
metamorphosis; the acid thus formed is conveyed to the venous system, and 
subsequently thrown out by the lungs. 

23. The entrance of oxygen, under these circumstances, into the circula- 
tion, has been a subject of much debate amongst physiologists. We have 
not time now to discuss the many ingenious hypotheses, advanced in favour of 
and against this view. They are all subject to grave objections, and I should 
have dismissed the matter, had not Professor Mulder's paper on the oxida- 
tion of protein reached me in time. From his analytical researches, it 
appears that protein, which is fibrine without its saline matter, is oxidized in 
the lungs by the reception of three equivalents of oxygen, and becomes C40H32 
Ns O15. In this way the oxygen is carried to every part, and wherever there 
exists a chemical affinity requiring that element, the fibrine abandons it pro- 
bably at the loss of its soluble state. In other words the conversion of 
oxygen by fibrine is attended with two results, the simultaneous supply of 
the gas to atoms undergoing eremacausis, and the deposition of fibrine in the 
proper point as a substitute for the loss. Hematosin is also recognized by 
Mulder as a means of distributing oxygen. The view of Liebig that the 
means was the peroxidation of the iron of blood is unworthy of that splendid 
chemist. 

24. We are now prepared to answer the query proposed — What is the 
character of the decay fibrine undergoes within the animal body, in its ulti- 
mate change ? The features of putrefactive fermentation and complete ere- 
macausis (6) have been given ; to neither of these processes does the change 
belong. Neither gaseous carburets, sulphurets, or phosphurets are produced 
as in fermentation, nor is all the carbon converted into carbonic acid, and the 
hydrogen not consumed in forming ammonia united with oxygen to generate 
water. The former of these compounds marks a minimum of oxygen, the 
latter a great abundance. Time is an essential element in these changes, for 



1844.] Gardner on the Influence of Oxygen. 23 

if the action be reduced to a minimum, abundance of oxygen being present, 
a portion of the nitrogen will also be oxidized or converted into nitric acid. 

The decay of fibrine in the frame is also dependent upon the oxygen, but 
takes its character neither from excess nor deficiency of supply. The reason 
is to be found in the capacity of the lungs. To convert all the carbon into 
carbonic acid and 320 atoms of hydrogen into water, would require the 
absorption of 1680 atoms of oxygen more than the fibrine contains; but by 
separating a portion of these elements in the form of urea and uric acid, the 
amount of oxygen necessary for metamorphosis, is considerably diminished. 
The lungs cannot, under ordinary circumstances, supply sufficient oxygen for 
complete eremacausis. 

25. That the capacity of the pulmonary apparatus and frequency of respi- 
ration are the true causes of the peculiar decay or sub-eremacausis of the 
living frame, is proved by the changes which occur in the products of the 
urine. The amounts of urea and uric acid are perpetually fluctuating. In 
persons who are active, urea is considerably in excess, or the sole result, 
while in sedentary persons, and those who suffer from confinement, uric acid 
increases in proportion. Urea contains more oxygen than uric acid, for 
urea equals C2H4N2O2, or carbon 2, oxygen 2, and uric acid, (C10N4H4O6) 
only 6 of oxygen to 10 of carbon. 

26. It is unnecessary to state that the decay of parts is essential to the wel- 
fare of the whole- — that upon the cessation of atomic metamorphosis, the 
destruction of the system ensues. The nature of the decay we have reduced 
to one primary condition, the amount of oxygen entering the body, but there 
are disturbing causes which control the quantity, and direct the metamor- 
phosis of parts. These are, frequency of respiration and the nervous power. 
The balance of these three component forces cannot be disturbed without the 
production of change, which may eventuate in disease. Let the respirations 
become greatly increased, larger amounts of oxygen enter, the fibrine in the 
blood is converted in excess into the tritoxide of Mulder, which is identical 
with the huffy coat of the practitioner^ the transfer of the oxygen therefrom to 
various parts of the body, exalts the temperature by hastening the changes of 
metamorphosis, more urea is produced (Prout) — in other words, a fever is 
the result. 

27. The amount of oxygen entering controls the result. If, then, the 
nature of the decay be dependent upon an external agent, what is the influ- 
ence of vitality in the process of metamorphosis? In other words, is this a 
case of vital change, produced under peculiar laws, independent and supe- 
rior to chemical laws, that is by the vital force ? I answer it is not, that the 
process is purely chemical, and subject to no disturbance whatever; the 
places where change takes place in the economy, are regulated by other 
causes, not by the admission of oxygen only, but the products of decay are 
formed solely under the agency of chemical forces. There is no difierence 
between the decay of fibrine necessary to health, and external decay, con- 



24 Gardner on the Influence of Oxygen, [July 

ducted in such a manner as to yield urea, uric acid, ammonia, carbonic acid 
and water. The real difference between the metamorphosis of animal mat- 
ter and similar external decomposition rests in this important particular, that 
in health the removal of one atom of fibrine is attended with the deposition 
of another, capable of performing the same function — this timely and essen- 
tial addition is the work of what may be called the vital force, for upon it 
vitality depends. 

28. Therefore the fibrine of the bodies of animals is subject to a peculiar 
decay, depending upon the access of oxygen, and being a sub-eremacausis 
whereby urea, uric acid, ammonia, water, and carbonic acid are produced. 
This may be termed vital eremacausis, because activity depends upon it, and 
as a means of separating the change from putrefaction, and complete erema- 
causis. 

Vital eremacausis owes its character to the circumstances — that it occurs 
at a fixed temperature, 98° F., that the supply of oxygen to the amount of 
fibrine changed is rigorously limited, and the time in which it takes place is 
also determinate. Alter any of these conditions, and the nature of the decay 
changes; there is nothing specific in it; the amount of change may bring 
about disease, but if radically altered, death is the result. 

Nor am I chargeable with examining the effect instead of the cause. 
Fibrine, as such, whether in the texture of an animal, or in the laboratory, 
like every other definite chemical compound, is so constructed that its atoms 
are in equilibrio, — it has no innate power of change, but when removed from 
external agencies may remain j^6nne to eternity. It is altered only by ex- 
ternal causes, and the product depends upon the cause. In the human body, 
the causes of change are oxygen and moisture ; these, therefore, must be 
present primarily, or, in other words, inspiration of oxygen is the first act of 
existence. 

The metamorphosis of matter is, therefore, the cause of activity, for no 
particle of fibrine undergoes decay without the production of those mole- 
cular forces which are the producers of heat, light, electricity, and other 
eflfects. If the metamorphosis is hastened, as by the use of protoxide of 
nitrogen, or by rapid inspiration, the activity is heightened — in these cases, 
an increased quantity of oxygen enters in a given time, but must be appro- 
priated; it cannot be rejected as an element from the system, and it therefore 
acts upon more atoms of fibrine. 

It will be perceived, however, that the oxygen diff'used throughout the 
economy by the blood, has not the power of spontaneously deserting the 
fibrine (with which it is combined, according to Mulder), but does so only 
under the influence of molecular forces. Were it otherwise, the oxygen 
would act exclusively upon the first atoms of fibrine it encountered — but we 
know that changes may become much more active in one part of the body 
than another, without respect to its distance from the lungs. There is, 
therefore, a power which protects one atom of fibrine, whilst it exposes 



1844.] Siille on Cyanosis. 25 

another to decay. Without the existence and recognition of this force, the 
action of oxygen would be destructive instead of sanative, and no chemical 
theory is tenable without it. What the force is, or whence it originates, is 
not for discussion now; there is no question that it manifests itself through 
the nervous system. It has nothing to do with the products of eremacausis, 
for whenever an atom is abandoned to the action of oxygen, chemical forces 
only come into operation. 

It may be agreeable to call the directing force vitality or vital force, for it 
undoubtedly regulates waste and supply, directs motion and growth, but it 
does not act in violence to chemical or mechanical forces. 



Art. II. — On Cyanosis^ or Morbus Cxruleus. By Moreton Stille, M. D.* 

Cyanosis, or Morbus Cceruleus, by either of which terms the disease we 
propose to treat of is sufficiently well designated, had not attracted, until of 
late years, much notice from medical writers. It is indeed true, that eases 
of the disease are to be found scattered through the periodical works of the 
last century, and that, as faithful portraits of its more striking features, they 
are unexceptionable; but we have to regret their imperfect description, in 
many instances, of structural alterations, and often the entire want of any 
account of these conditions. Had the value of these signs been always duly 
appreciated, the knowledge of the true pathology of the disease would not, 
perhaps, have been so long obscured, and the ingenuity expended in the 
support of fanciful hypotheses would have been more usefully employed in 
legitimate inferences from well ascertained facts. Several treatises on cyano- 
sis, and chiefly from the pens of the French and German writers, are now 
extant, and have been regarded as containing all that was known of its patho- 
logy. The doctrines advocated in them have received a general and tacit 
assent, but we think that they will be found to be the offspring of a too nar- 
row observation, and to embody speculative notions rather than sound prin- 
ciples. 

The first approach to a more correct mode of investigation was made by 
M. Gintrac, of Bordeaux, who, in 1814, wrote an inaugural thesis upon 
this subject. Ten years after its publication it was again issued, in a more 
complete form, M. G. having, in the mean time, much extended his re- 
searches, and somewhat modified hi« opinions. His essay contains the 
history of 53 cases of cyanosis, collected by him from various works, some 
of which were rare, and difficult of access. M. Louis, in 1823, published a 

* This paper was presented us an Inaugural Thesis to the Medical Faculty of the 
University of Pennsylvania, in January, 1844, and is now published in compliance with 
their unanimous request. 

No. XV.— July, 1844. 3 



26 Stiile on Cyanosis, ' tJu^y 

short treatise upon '*The Free Communication between the Right and Left 
Cavities of the Heart," and founded his views of the pathology of the dis- 
ease upon a consideration of eighteen cases. 

From these cases, and from others which we have ourselves collated, it is 
now proposed, as preliminary to the examination of some controverted points, 
to give a brief general description of cyanosis, and its more important struc- 
tural alterations, and while confining ourselves within the limits of well- 
attested facts, to avoid, for the moment, any assertion as to the relative 
frequency or value of either symptoms or lesions. 

The sense in which we shall use the word cyanosis, is that of a blue dis- 
coloration of the skin and mucous membranes referable to some organic 
lesion of the heart or its great vessels. To define the disease more strictly 
would be a transgression of the present limits of our pathological know- 
ledge, and however desirable the establishment of a positive and well sup- 
ported cause of the disease may be, we shall be able, in the course of this 
article, to show into what serious errors and inconsistencies an over-hasty and 
too restricted a definition has led. 

Cyanosis is met with chiefly in the earlier periods of life, occurring con- 
genitally, or showing itself a few years after birth. When not congenital, 
its approach may be gradual, and the first indications of a disturbed circula- 
tion so slight as scarcely to attract notice; or, on the other hand, its invasion 
may be sudden, and complete discoloration be at once established. If, as 
is sometimes the ease, cyanosis has first made its appearance in mature 
years, the attack is often referred by the patient to some antecedent injury, 
as a severe blow or fall. The extent and intensity of the discoloration vary 
in different cases, and at different periods in the life of the same individual. 
When it is but partial, it is most marked in the lining membrane of the 
mouth, upon the lips, cheeks, extremities of the fingers, and in those parts 
generally where the skin is delicate, and the capillary vessels numerous. 
The colour varies in its shades, from a mere livid tint to the most complete 
blackness, and is more marked in all violent efforts, and under the influence 
of strong moral impressions. If paroxysms occur, the discoloration will 
be deepest during their continuance, while in the remissions it may be but 
slight, or even entirely absent. The discoloured parts are also, at the same 
time, more or less cedematous. The external temperature of the body may 
be perfectly natural, or, on the other hand, so much lowered as to render the 
situation of the patient very distressing. In these latter cases the body seems 
incapable of receiving warmth, and the patient is chilled even in the hottest 
days of summer. The functions of digestion and secretion do not seem to 
be altered in any marked degree, but those of circulation and respiration 
exhibit the greatest deviations from the healthy standard. While the patient 
is in a state of repose, his breathing may be calm and regular. In some 
cases, however, the dyspncea is habitual, but in all it is either induced or 
aggravated by any cause tending to excite the circulation. For this reason 



1844.] ' Stille on Cyanosis. 27 

persons affected with cyanosis, are either averse from, or incapable of exer- 
tion, and in them a vivid moral emotion will often bring on great oppression. 
Some are thrown by these causes into the most alarming paroxysms ; the 
countenance becomes suddenly anxious and distressed, the surface livid, the 
respiration hurried and gasping, and the movements of the heart tumultuous 
and irregular. A state of syncope follows, in which the patient may lie for 
several hours. In some cases the paroxysms occur without any obvious 
exciting cause, and it is in one of them that the fatal issue takes place. The 
following lesions, defects, and alterations of structure of the heart and its 
great vessels, have been found in persons who have, during life, been affected 
with cyanosis. 

1st. Dilatation and hypertrophy of the right cavities of the heart. 

2d. Contracted state of the left cavities. 

3d. A heart consisting of but one cavity. 

4th. A heart with two cavities, an auricle and a ventricle, 

5th. A heart with two auricles and one ventricle. 

6th. Persistence of the foramen ovale, or a cribriform condition of the 
auricular septum. 

7th. Deficiency of the ventricular septum at its base, or an entire absence 
of it. 

8th, Dilatation of the aorta. 

9th. A rudimentary condition of the pulmonary artery, contraction of it, 
adhesion of its valves, deficiency of one or more of them^ cartilaginous or 
other growths at its orifice, or complete closure of it by membranous septa, 

10th. Persistence of the ductus arteriosus. 

11th. Contraction of the right auriculo-ventricular opening. 

12th. Transposition of the aorta and pulmonary artery. 

13th. The aorta and pulmonary artery arising from one ventricle. 

14th. The aorta and pulmonary artery arising from a common trunk. 

15th. The aorta giving off branches to the head and upper extremities, 
and the pulmonary artery forming the aorta descendens. 

16th. The aorta giving off two pulmonary branches. 

Some of these anatomical dispositions are often coincident, and in another 
place we shall endeavour to indicate their more frequent and important com- 
binations; at present, however, it will be sufficient to note the great variety 
of pathological conditions that have been found in cases of the disease under 
consideration. The concurrent lesions of other organs, although well de- 
serving of attention after the establishment of a well-founded theory of 
cyanosis, can be of little use in the investigation we are entering upon ; for 
they are, for the most part, either secondary effects of the disturbance of the 
respiratory or circulatory functions, or mere accidental complications. The 
elements essential to the production of the disease manifestly reside in the 
heart and great vessels; to these, therefore, must our attention be mainly 
directed if we wish to discover its laws of causation. 



28 ' Stille on Cyanosis, [July 

The phenomena of cyanosis have been, by different writers, referred to 
one or other of the following causes. 

1st. Obstruction to the return of the venous blood to the lungs. 

2d. Presence of the venous blood in the general arterial system. 

The first of these modes of explanation has been adopted by Louis, Berard, 
Bertin, and Ferrus among others, and has been regarded as an occasional 
cause by some of the advocates of the other view of the pathology of the 
disease. The class which takes this middle course is, perhaps, more nume- 
rous than either of those which maintain an exclusive doctrine, and whatever 
may be said of the consistency of thus admitting in turn one or other of two 
conflicting theories as may suit convenience, it certainly is a safe refuge from 
absolute error; for whichever may eventually be found to be incorrect, this 
class can never be wholly in the wrong. Among those who maintain the doc- 
trine of the mixture of arterial and venous blood as the cause of cyanosis, may 
be mentioned, Morgagni, Senac, Corvisart, Caillot, Labat, Bouillaud, and 
particularly Gintrac, to whose industrious researches we have been much 
indebted in the present investigation. It may be mentioned here, that 
while the presence of venous blood in the general arterial system was con- 
sidered by these writers the essential cause of cyanosis, they did not limit 
the mode of its production to any one anatomical condition of the heart; 
many, however, espousing their views, have thoughtlessly narrowed down 
the means of communication allowing the admixture of the blood to that 
one which is the most frequently met with, viz., an opening in the auricular 
septum, so that at present, and particularly in our own country, cyanosis 
and an open foramen ovale, are very generally regarded as inseparable. This 
untenable modification of the more general statement would hardly demand 
notice, were it not for its great prevalence, and the confidence with which 
remedial measures are sometimes based upon it. 

Notwithstanding, however, all that has been written upon the subject, the 
pathology of cyanosis cannot yet be considered as resting upon stable grounds. 
The affection is one of rare occurrence, presenting a great variety in the 
character of its phenomena and post-mortem appearances. Manifestly, 
therefore, the history of one or two isolated cases can never entitle the 
observer to establish a general law of the disease. Nor, again, can the 
collation of a large number of recorded cases be of any value if deduc- 
tions be made, not from the cases themselves, but from the opinions of 
those who have observed them. These last may be, and very often are, 
founded upon imperfect examinations; prejudice, ignorance, and many other 
causes, may render the conclusions obtained valueless, and one who, from such 
materials, should expect accurate results, could hardly fail of disappointment. 

It is also evident, that although in the majority of instances some one 
symptom or lesion may have been found constant in its occurrence, yet its 
mere frequency is apart entirely from the importance it may claim in the 
history of the disease. For example — the striking discoloration of the skin 



1844. J Stille on Cyanosis. 29 

from which cyanosis takes its name, is entirely absent in some cases in 
which the structural alterations, regarded by some as the essential cause for 
its production, exist; and yet if the comparative frequency of their occur- 
ence were alone to be received as a sufficient test of the value of their rela- 
tion to this symptom as cause and effect, we should be led into the error of 
admitting that to be essential to the production of the discoloration, which 
facts had proved was not so. It would not be difficult, indeed, to trace to its 
true cause the proneness to fall into this logical error; it requires but feeble 
persuasion to convince us of what we are already disposed to believe, and no 
one can be safe from the mistake of admitting a plausible explanation as a 
true one, if he be in search of arguments to sustain some preconceived and 
favourite theory. To consider dispassionately, and with equal care, all the 
facts presented to our observation is an indispensable requisite in any investi- 
gation, and the most certain way of practically insuring it, is the adoption 
of some method of examination, by which the erroneous influence of even 
an unconscious leaning to any particular doctrine may be precluded. The 
plan pursued in the present essay will be found to present this advantage 
among others. All the attainable cases on record in the periodical works, 
and in the treatises on cyanosis have been collated, condensed, and subse- 
quently arranged in a tabular form, the prominent points of interest in each 
being, at the same time, placed under their appropriate heads. In this 
manner upwards of 80 cases have been examined, the results of which we 
shall be enabled to present in the following pages. 

The two theories of the pathology of cyanosis having been stated above, 
let us now examine to what extent they are consonant with the facts thus 
obtained — and 

1st. Of the presence of venous blood in the general arterial system. 

The conditions necessary for this result, are, abnormal communications 
between the right and left cavities of the heart, or such a disposition of the 
principal vascular trunks as will allow their contents to intermingle. When- 
ever the black is brought into contact with the red blood, the colour result- 
ing from the contamination is intermediate, or of a purple hue. If then, as the 
advocates of this doctrine maintain, there can be no discoloration of the 
skin, without this admixture of arterial and venous blood, we should always 
find, in cases where discoloration existed, some one of the communications 
abovenamed, for it is evident, that this explanation being an exclusive one, 
must, if true at all, be true of all cases. 

In five cases, however, (the authorities for which are cited below,*) neither 
the foramen ovale nor the ventricular septum was open, nor did there exist 
any other passage by which the arterial and venous blood could com- 
mingle. Yet in all of these, there was the discoloration of the skin which 

* Archives Gen. de Medecine, vol. viii. p. 594. Bouillaud, Malad. du Cceur, Obs. 77, p. 
155. Edinburgh Med. and Surg. Journal, vol. liii. p. 552. Ibid. 1830. Lend. Med. and 
Phys. Journ., vol. xiv. p. 471. 

3* 



30 Stille on Cyanosis, [July 

is characteristic of cyanosis ; in two it was partial in extent, in three com- 
plete. The other phenomena of the disease were likewise present. In a 
future part of this paper, these cases will be again taken up; the facts perti- 
nent in this place, are those already stated, and they prove, \st, That cya- 
nosis may exist without admixture of the blood. 

Again, the communications permitting this admixture, being of very fre- 
quent occurrence in cyanosis, it is rarely that cases are to be found, illustrat- 
ing like the preceding, the want of relation between the disease, and its 
alleged pathological cause ; as these communications vary, however, in their 
seat, and in the degree in which they will allow the access of the venous to 
the arterial blood, there should be a difference in the depth and extent of the 
cyanosis corresponding to the degree in which the blood is mingled. But 
numerous cases of the continued patescence of the foramen ovale are on re- 
cord, in which, nevertheless, no symptoms of cyanosis had been manifested. 
Cases, also, of partial deficiency of the ventricular septum, without any 
accompanying discoloration of the skin, are of not infrequent occurrence. 
Setting aside these points altogether, as being open to some doubt in regard 
to the amount of blood vitiated, it will conduce more to a correct understand-, 
ing of the actual relations of the discoloration with the mixture of the blood, 
if we examine those cases only in which the latter was not merely possible, 
but inevitable. In such, of course, the discoloration should bear a certain 
proportion in extent and intensity, to the degree in which the arterial was 
adulterated with the venous blood. 

The four following cases are examples of this kind ; we have annexed to 
each the amount of the discoloration as stated by those who observed them. 

1. Ventricular septum open, aorta arising from the right ventricle, — no 
cyanosis except an occasional lividity of the lips.* 

2. No pulmonary artery. Aorta arose from both ventricles, and gave off 
large bronchial branches. -Face only cyanosed. Age 16 years. f 

3. Heart with two cavities ; the aorta and pulmonary artery arose from 
a common trunk. The lips livid upon the day of his birth, and that of his 
death. Age 7 days.ij: 

4. Heart with two cavities. Aorta gave off two pulmonary branches. 
Cyanosis slight and remitting. Age 3 days.§ 

In all of these cases, there was of necessity a thorough admixture of the 
blood, and a contamination thereby of the whole circulating fluid, altering its 
colour at the same time that it vitiated its character. So complete, indeed, 
was this vitiation, that it is difficult to understand how it was compatible with 
life. If a mere perforation of the auricular or ventricular septum were ade- 
quate, as is affirmed by some to the production of a general and marked 
discoloration of the skin, and the other phenomena of cyanosis, certainly 
we should have been warranted in anticipating at least an equal result in 

* Lond. Med. and Phys. Journ., N. Ser. vol. vi. p. 548. t Ibid. 

\ Gintrac, Recherches sur la Cyanose, p. 44. 

§ Farre, Pathol. Essay on Malform. of Heart, p. 2. 



1844.] Still e on Cyanosis. 31 

these instances. For if the effect bear any proportion to its alleged cause, the 
individuals in whom the lesions just named were found, should have offered 
the symptoms of cyanosis in the extreme. But, so far from this, it will be 
seen that in those cases affording the means for the most complete mixture of 
the blood there was the least discoloration. These four cases prove, 

2d. That there is no proportion between cyanosis, and the degree in 
which the blood is mixed. 

So great, indeed, is this disproportion, that these cases would render it 
highly probable that it may sometimes amount to an entire want of connec- 
tion, but this is conclusively demonstrated by the two following cases. 

1st. Foramen ovale open ; pulmonary artery arose from both ventricles, 
gave off pulmonary branches, and formed the aorta descendens. The aorta 
gave off the arteries of the head and upper extremities, and joined the pul- 
monary artery by the ductus arteriosus ; no cyanosis. Age 8 months.* 

2d. Heart with two cavities ; aorta and pulmonary arising from the ven- 
tricle; no cyanosis. Age 11 days.t 

We are now entitled to proceed one step further, and to state the converse 
of the first proposition — viz: 

Sd. That complete admixture of the blood may take place ivithout cya- 
nosis. 

M. Gintrac, who is, as we have before said, the most strenuous supporter 
of the doctrine of the mixture of the blood as the cause of cyanosis, encoun- 
tered the difficulty presented by the cases just cited. Having met with several 
instances of the origin of the aorta over the ventricular septum, or in other 
words, from both ventricles, and in which cyanosis did not occur till several 
years after birth, he asks — " How shall we account for this late appearance 
of cyanosis ?" " Must not the venous blood in these cases mingle with the 
arterial? Does there exist, in the early periods of life, any obstacle to this 
mixture ? I think not. I am inclined to believe that, in new-born children, 
the two kinds of blood differ less, than at a more advanced age. The first 
inspirations produce in the organism a general stimulation ; immediately 
the skin appears of a brilliant colour, the heart and vessels are strongly ex- 
cited, the circulation of the blood is rapid, and from this activity, this velo- 
city in the course of the fluid, result on the one hand, less considerable losses 
of the vivifying principles in the general capillary system, and on the other, 
a more prompt reparation in the capillary system of the lungs." 

These sentiments have been quoted in M. G.'s own words, as it was feared 
that, if abbreviated, they might not be conveyed with sufficient precision. 
We would be reluctant to receive an hypothesis so gratuitous as this, as a 
satisfactory explanation of a well-established fact. That an increased velo- 
city in the current of the blood is a reason why it should part with less of 
its vivifying principles, is a novel proposition in physiology, and one which, 

* Farrc, Pathol. Ess. p. 15. t Am. Journ. of Med. Sciences, Oct. 1843, p. 447. 



32 Stille on Cyanosis. [July 

we believe, will not stand the test of the most cursory examination. Is the 
nutrition of the young and growing being less active than the same process 
in the adult, and does not this function depend upon the surrender of what 
are vaguely termed " the vivifying principles ?" What, in fact, is the object 
of the "prompt reparation" of the blood in the lungs if not to restore to it 
anew those " vivifying principles" which, in its route through the body, it 
has just yielded up ? Adopting this hypothesis as a sufficient explanation of 
the absence of cyanosis in new-born children, where there was an unequi- 
vocal mixture of the two kinds of blood, it then became necessary for M. 
Gintrac to show how it was that cyanosis was ever congenital. He says 
that the action of the air on the lungs was, " in these cases, incomplete, im- 
perfect, almost null. In most of them, in fact, the pulmonary artery was 
contracted, or even obliterated at its origin." 

One of the effects of the contraction or closure of the pulmonary artery, 
supposing no compensation for the same to exist, and to which M. G. refers, 
would be, that a less amount of blood would reach the lungs. And the idea, 
which doubtless is here implied, is, that, therefore, the whole of the circu- 
lating fluid must be of a venous character, and give, in consequence, its 
colour to the skin. But, although the blood arrive at the lungs in a dimi- 
nished quantity, there is no reason why ihe hsematosis of this should not be 
complete ; and the only influence that such a condition could exert upon the 
the character of the circulation, would be that it would diminish the mass of 
the arterial blood. M. Gintrac's views of congenital cyanosis involve then, 
not only an abandonment of his theory of the mixture of the blood, (which 
is, indeed, acknowledged by him to be insufficient,) but also of that of defi- 
cient hsematosis, which is substituted in its place. 

Having now seen the discrepancy existing between the occurrence of 
cyanosis, and the pathological conditions to which it has been referred, we 
shall here only subjoin one fact, which the cases we have collected have 
enabled us to determine, and which is, at the same time, confirmatory of the 
three positions already attained. If there be preternatural communications 
in the heart, or its great vessels, and the mixture of the blood has ever taken 
place, it must continue to do so. Moreover, the degree in which the arterial 
blood is deteriorated, will remain relatively the same; for although the heart 
may, under the influence of many causes, propel its contents with greater 
vigour, yet as this increased energy is shared alike by both sides, the dis- 
coloration can be no greater, as the amount of blood mingled is relatively 
the same as in a state of repose. Hence, it follows that there ought never 
to be any variation in the same individual of either the extent or intensity of 
the discoloration. It should be permanent. Such is, indeed, in many 
instances the case, a circumstance which, in another place, will be ascribed 
to what we consider its true cause. But in all cases in which the blood is 
mingled, the discoloration should be unvarying in its shade and extent, if 
upon that condition alone it depends. We have noted 77 cases in which 



1844.] Stille on Cyanosis. 33 

there were means for the mixture of the blood to take place. Of this num- 
ber there were 29 in which the colour was constant in its extent or shade, or 
in which these particulars were not a subject of observation. In the remaining 
48 there was a variation either in the depth, extent, and progress of the dis- 
coloration. In some the lips alone, in others these, the cheeks, the chin, 
and the extremities of the fingers and toes were cyanosed, and again in 
others the whole body was implicated; a light brown, a violet or livid hue, 
or the utmost blackness, were to be seen at different periods in the same 
individual, and these shades, passing into each other insensibly, while they, 
in some, did not permit the skin to return to its natural colour, in others 
allowed the remission to be complete and the skin natural, until the super- 
vention of certain exciting causes reproduced the morbid appearance. The 
designation of the mode in which these causes act is reserved for another 
place; but from the evidence of these facts we are warranted in concluding, 
that as the mixture of arterial and venous blood is a cause acting with uni- 
formity at all periods, it follows, 

4th, That the variation in the extent, depth, and duration of the disco- 
loration is inexplicable by the doctrine of the mixture of the blood. 

It is presumed, that sufficient data have now been obtained to place the 
fact beyond cavil, that cyanosis cannot be referred to a mixture of arterial 
and venous blood as its cause. In estimating the value of these objections 
to the popular theory, let it be remembered that they claim no farther validity 
than that which belongs to the facts upon which they are based; the justice 
of the inferences we have made it is in the power of any one to verify. The 
rejection of this theory, however, does not impose upon us the necessity of 
adopting in its place any other with merely plausible pretensions; for as this 
has been abandoned only after full proof of its incorrectness, so can any 
other be entitled to reception only by resting its claim upon satisfactory 
grounds. Nor, indeed, could our inability to offer any adequate explanation 
of cyanosis, invalidate in the least the objections we have urged against the 
doctrine of the mixture of the blood, for the arguments by which this, or 
any other theory which shall account for its phenomena on distinct princi- 
ples, is upheld, are independent; an insufficient refutation, therefore, on the 
one hand, or inadequate confirmation on the other, cannot necessarily imply 
the correctness of the opposing doctrine. Nevertheless, all will admit, that 
where two theories, both of which cannot be true at the same time, are 
proposed to account for certain morbid phenomena, if one of them can be 
proved, from careful examination, to be unsupported by the evidence of well- 
observed facts, there results in favour of the other a higher presumption, 
which may be the more easily elevated into demonstration, inasmuch as it is 
then sustained, not only by positive, but by negative proof. It has been 
mentioned before that there is but one other method of explaining the pheno- 
mena of cyanosis, viz: — that which ascribes it to a congestion of the general 
venous system, resulting from some obstruction in the right side of the heart, 



34 Stille on Cyanosis, [Juty 

or in the pulmonary artery, impeding the return of its blood to the lungs. It 
is now proposed to examine the basis upon which this doctrine rests, in order 
to determine whether or not it be entitled to our belief. We shall pursue 
the same mode of investigation in the examination of this theory as in that 
of the other; therefore, if true, the structural lesion which it assumes must 
fulfil the three following indications. 

1st. That it shall account satisfactorily for the discoloration of the skin 
and the dyspnoea. 

2d. That it shall be found in every case of cyanosis, or if not, there shall 
exist in its place some cause acting upon similar principles. 

3d. That it shall never be found without the concurrence of cyanosis, or 
if it is, that a satisfactory explanation of the exception shall be given. 

1st. Does the contraction, obstruction, or imperforation of the pulmonary 
artery account satisfactorily for the discoloration of the skin and the dysp- 
noea? The fact is a familiar one, that any cause impeding the return of the 
venous blood to the heart will produce a congestion in the veins exterior to 
the locality of the obstacle, which, according to the time the impediment 
remains, will manifest itself by giving a bluish or blackish tinge to the part. 
The appearance of the arm when, in the operation of bleeding, the ligature 
has been too tightly applied, is an example of partial cyanosis. If, how- 
ever, the impediment be seated nearer the central organ of the circulation, in 
the air passages, as in croup, or in the lungs, as in pulmonary congestion, 
the cyanosis is then general, affecting first, however, the veins of the head 
and face, because of their proximity to the cause of the obstruction. Is it 
not, then, a reasonable inference, that, if the pulmonary artery, which is the 
grand outlet for the venous blood returning from every part of the body, be 
either obstructed at its orifice or narrowed in its calibre, the whole venous 
system must be consequently congested? Moreover, where these obstruc- 
tions of the pulmonary artery exist, the capillary vessels must be constantly 
more or less distended, and it is highly probable that this state of dilatation 
must destroy, in some degree, their tonicity, and favour still more the stasis 
of venous blood in them. For this reason we should expect to find the dis- 
coloration chiefly manifest in the most vascular parts, and in those also 
which, being remote from the centre of the circulation, have the current in 
them proportionably sluggish. This, indeed, is consistent with general 
observation, and we find, accordingly, that the mucous membranes, the lips, 
the cheeks, and the ends of the fingers and toes, are the first to manifest the 
congestion. The pressure of venous blood upon the right side of the heart, 
resulting from an obstruction in the pulmonary artery, distends the cavities 
of that side, and from this distension, and the resistance to the due perform-, 
ance of their functions in consequence of the obstacle to the exit of the blood, 
they become often permanently dilated and hypertrophied. Of 53 cases of 
cyanosis in which the pulmonary artery was either contracted, obstructed or 
impervious, the condition of the right cavities was the subject of observation 



1844.] Stille on Cyanosis. 35 

in 36. The right auricle was dilated in 15 cases, and dilated and hyper- 
trophied in 7. The right ventricle was dilated in 10, hypertrophied in 13, 
and dilated and hypertrophied in 12. The state of the left cavities of the 
heart was observed in 33 cases of the same series. The left auricle was 
contracted in 9, dilated with thinning in 1, and natural in 3. The left 
ventricle was contracted in 12, dilated in 3, thinned in 3, and natural in 3. 
We would state here, that we are not willing to rely upon these results, and 
especially on those which regard the condition of the left cavities of the 
heart, as exact, it being highly probable that in hasty or imperfect examina- 
tions, slight differences may have been exaggerated, or really valuable indi- 
cations overlooked; yet the peculiar character of the deviation from the 
healthy standard, as exhibited in a diminution of the sizcNof the left side, 
and a dilatation and hypertrophy of the right, is too remarkable to be passed 
by, and the dependence of the latter upon the obstruction to the passage of 
the blood through the pulmonary artery too probable to be admitted with 
much reserve. When considering the question whether or not the mixture 
of the blood was the essential cause of cyanosis, it was shown, from cretain 
cases then quoted, that there was such a disproportion between the pheno- 
mena of the discoloration, and the cause assigned for their production, that 
it was impossible to view them in the relation of cause and effect, and it was 
also shown, that the great variation in the extent and in the shade of the dis- 
coloration, was inexplicable by a cause acting with uniformity at all periods. 
Upon examining those cases in which the pulmonary artery was either con- 
tracted, obstructed, or impervious, with a view to ascertain how far the 
character of the discoloration was influenced by these conditions, we find, 
that of 53 cases of cyanosis, in which the former was observed, the latter 
was mentioned in 36. In all of these 36 cases there was a variation in its 
extent and intensity. Such a result is easily explained by the anatomical 
conditions. For it is well known that the colour is deepened and increased 
in extent under the influence of emotional causes, or of slight bodily excite- 
mient; and as the ordinary result of these is an increased activity of the circu- 
lation, and of the flow of blood through the pulmonary artery, an obstruction 
of this vessel would, of necessity, cause a turgescence of the whole venous 
system, corresponding in degree to the grade of the excitement, and pro- 
ducing a like variation in the discoloration of the skin. 

Dyspnoea is a striking feature of cyanosis, and frequently recurs in parox- 
ysms under the influence of mental or bodily excitement. If the blood be 
sent to the lungs in a quantity less than is required for the discharge of the 
function of haematosis, an attempt is made to compensate for this deficiency 
by an increased frequency of action ; but if the movements of the heart be 
suddenly augmented in energy, there is, of necessity, a greater amount of 
blood thrown upon its right cavities, and the lungs expand, at the same time, 
more rapidly to receive it. The pulmonary artery, however, being obstructed, 
and the right cavities distended with the accumulated blood, its escape, except 



36 Stille on Cyanosis. [^"^7 

in small quantities, is prevented, and the action of the lungs, thus rendered 
ineffectual, becomes like that of the heart, laboured and irregular, until at 
last syncope supervenes, and gives a short repose to those organs whose 
continued action vras only adding, each moment, to the obstacle they vi^ere 
endeavouring to surmount. The state of the respiration was the subject of 
observation in 39 of the cases we have collected. In 3 of these the condi- 
tion of the pulmonary artery was not observed, but in the remaining 36, in 
all of which the artery was either narrowed or obstructed, the dyspnoea was 
habitual, and speedily increased by movement or by moral impressions. 

2d. Is the contradioyi or partial or complete obstruction of the pulmonary 
artery to be found in every case of cyanosis, and if not, is there in those 
cases lohere it is wanting, an efficient cause of a similar character? 

There is one difficulty which presents itself on the very threshold of this 
inquiry. It may be thus simply stated. The common lesion of the pulmo- 
nary artery in cyanosis seems to have been unknown to a great number of 
observers, while that of the foramen ovale was known to all. The latter 
was then sought for in all cases of cyanosis, while the former may, in many, 
have been neglected. The popular opinion in regard to the efficiency of the 
open foramen in producing the disease was, no doubt, an additional reason 
why the state of the pulmonary artery was not observed in every case. We 
•would not, perhaps, be warranted in taking it for granted, that, in all those 
cases in which all the pulmonary artery was not observed, the lesions above- 
mentioned might, upon examination, have been found, although we would 
have good reason to infer this to have been the fact from the large number of 
cases, similar in all respects, in which the pulmonary artery was either con- 
tracted or obstructed. To avoid, however, introducing into estimates, which 
we wish to render as accurate as possible, an element, whose value we can- 
not ascertain, those cases only in which the pulmonary artery was observed, 
will form the basis upon which we shall proceed. 

The pulmonary artery was observed in 62 cases. In 53 of these, it was 
either contracted, obstructed, or impervious. The remaining 9 cases pre- 
senting the phenomena of cyanosis without any one of these anatomical condi- 
tions existing, fall under the category of those cases, which, in accordance 
with a previous statement, must be examined in order to determine whether 
they act upon the same principle. Of these cases it is stated that the pulmo- 
nary artery was in — 1 natural; 1 dilated; 1 aneurismal; 1 communicated with 
the aorta ; 1 arose from the left ventricle ; 2 given off by the aorta ; 1 given 
off in two pulmonary branches by the aorta ; 1 absent, but bronchial arteries 
large. 

1st. In the first of these cases, the patient was a young man, who died at 
the age of 18 of an "insidious fever." During the last ten years of his 
life, he had been the subject of observation. His history, previous to that 
period, is entirely omitted, and thus one important fact, viz., the date of the 
attack, is left entirely to conjecture. The violet colour of the skin and lips 



1844.] Stille on Cyanosis. 37 

diminished or augmented every moment, according to his impressions, his 
attitude and movements, and the difficulty of his digestion .or respiration. 
Upon post-mortem examination, evidences of sanguine congestion were 
found everywhere. The heart was large, and all its cavities filled with a 
semi-fluid black blood ; the walls of the left ventricle were less than three 
lines in thickness, while those of the right ventricle were six lines thick, and 
the columnse carnese so much developed, as almost completely to obstruct the 
cavity of the ventricle. The auricular septum offered an opening of three 
lines in diameter. The effect of this almost complete obliteration of the 
cavity of the pulmonary ventricle can hardly be misunderstood. The 
amount of blood received by it could have been but very small, and there 
being provided no adequate compensation for the resistance thus opposed to 
the discharge of venous blood into its cavity, the whole of that resistance 
must have been felt throughout the entire venous system. The right ventricle 
being thus obstructed, any cause exciting the circulation, and throwing an 
increased quantity of blood upon it, must have cast it into violent, irregular 
and fruitless action, and consequently brought on the whole train of distress- 
ing symptoms which the patient experienced. The structural lesion of the 
right ventricle was, in fact, operative almost precisely in the same manner as 
would have been an obstruction to the passage of blood through the pulmo- 
nary artery. It is a matter of regret that the early history of this case has 
not been recorded, as, from the progression of the symptoms, some light 
might, perhaps, have been thrown upon the rare occurrence of hypertrophy 
of the right ventricle unconnected with other lesions of the heart.* 

2d. A postilion, aged 57 years, received some violent blows upon the 
epigastrium, and during the three following weeks had dyspnoea, fainting 
fits and great pain in the part where the injury had been inflicted. These 
symptoms had subsided in a great degree when he received a new con- 
tusion in the same place. From that time he had palpitations, irregular 
pulse, suffocation on the least movement, cedema, ascites, &c. His face was 
livid or violace. How long he survived this last injury is not mentioned. 
The heart was "voluminous," the right ventricle very much dilated and 
hypertrophied, and its columns carnese as great as those usually found in the 
left ventricle. The right auriculo-ventricular opening was dilated, and the 
tricuspid valve proportionately enlarged. The cavity of the right ventricle 
was "enormous," its walls very thick, and the fleshy columns much deve- 
loped. "The left auricle was dilated and thinned, the left auriculo-ven- 
tricular opening very much contracted, and the mitral valve thickened and 
rugose." The cavity of the left ventricle was so small as scarcely to receive 
a walnut, its walls being at the same time slightly thicker than natural. In 
the fossa ovalis there was an opening of an inch in diameter, its border thin, 
loose, and tendinous. The aorta was, at its origin, very much contracted, 

* Gintrac, Rech. sur la Cyanose, p 98. 
No. XV.— July, 1844. 4 



38 Slille on Cyanosis, [July 

and the pulmonary artery dilated as far as its bifurcation, and its valves pro- 
portionately enlarged. It may be said that this cannot be quoted as a case of 
cyanosis, inasmuch as, previous to the reception of the injury above men- 
tioned, the patient was in good health. But it is certainly sufficiently cha- 
racteristic in the discoloration of the skin, and in the attendant symptoms, 
and so like in these to all the cases of acknowledged cyanosis in which the 
progress of the disease was gradual, that it may be ranked among them with- 
out the risk of violating any principle of arrangement. The symptoms 
recorded of this case are precisely those of all congestions of the venous 
system, where the cause of the obstruction is near the centre of the circula- 
tion. In this instance, the primary cause of the congestion may, we think, 
be found in the left side of the heart; the aorta being, as already stated, very 
much contracted, the left ventricle greatly lessened in capacity, and present- 
ing, in the thickened and contracted state of the auriculo-ventricular opening, 
an important obstacle to the discharge of the aerated blood. The right side 
of the heart, as will be seen from the remarkable development of its muscular 
apparatus, was acting with unnatural energy, and thus the whole pulmonary 
circulation must have been consequently congested. This engorgement 
reacting, at the same time, upon the general venous system, this system was, 
in its turn, subjected to the influence of the remote cause in the left side of the 
heart, retarding the blood in its course, and preventing its free ingress into 
the lungs.* 

3d. The case coming next in order is that in which the pulmonary artery 
was " aneurismal." The mode in which this condition would act in inducing 
venous congestion, is too evident to require illustration. The subject of it, 
aged 41 years, "was remarkable for the lividity of his complexion, the 
fulness of the vessels of the conjunctiva, and the thickness of his lips, 
■which were, at the same time, nearly black. The respiration was so much 
disturbed that he could not pronounce two consecutive words, and he died in 
a state of suffocation."! 

4lh. In this case the pulmonary artery was prolonged directly into the 
aorta, and its branches were given off from its posterior aspect. The 
heart full of black blood, and the foramen ovale open. The child who 
was the subject of this report lived but twelve hours. Its colour, which 
soon after birth was seen to be black, became gradually less dark, until 
it assumed a bluish tinge; the difficulty of its respiration increasing, how- 
ever, each moment, the skin became again perfectly black, and soon after- 
wards the child expired. The preservation, in this instance, of one of the 
characteristics of the foetal circulation in the continuance of the ductus arte- 
riosus, or (as stated in the report) the prolongation of the pulmonary artery 
into the aorta, and the failure to establish those new routes which the first 
act of inspiration should create, furnish us with a striking illustration of the 

* Bouillaud, Malad, du Coeur, p. 562. t Gintrac, p. 64. 



1844.] ^ ' Stille on Cyanosis, 39 

separate dependencies of uterine and extra-uterine existence. The placenta, 
it has often been remarked, holds the same relation to the foetus as the lungs 
to the breathing child. But the function performed in the one case by the 
placenta, in the other by the lungs, is, in each, essential to the maintenance 
of vitality. If, then, after the circulation through the placenta has been cut 
off, the blood does not find access to its new respiratory organ, or if it be 
sent there only in part, life is entirely extinguished, or but imperfectly sus- 
tained. The blood, dammed up from its natural reservoirs, surcharges the 
general venous system, and the phenomena of asphyxia, persistent in this 
case on account of the remediless nature of the malformation, become fully 
established. The gradual decline in the depth of the discoloration, and its 
sudden recurrence in all its intensity, denote the struggle that nature was 
ineffectually making to fulfil her ordinary law.* 

5th. In this case it is said that the pulmonary artery arose from the left 
ventricle. There existed, in fact, but one ventricle, the right being "rudi- 
mentary." The two auricles also constituted but one, as they formed " one 
large cavity without the least separation." The left auriculo-ventricular 
opening " was very much contracted, and its valve formed a cylindrical canal 
capable of receiving the index finger." The corresponding opening of the 
right side was "a little orifice of three lines in diameter, with a valve made 
of a fold of the lining membrane of the heart." The pulmonary artery was 
destitute of valves. A concurrence of such remarkable defects and alterations 
of structure of these could, of course, not have existed without a very serious 
interference with the general health. And the manner in which such dis- 
turbance was effected, cannot, we think, be a matter of doubt. By the 
morbid alteration of the valvular apparatus of the ostia venosa, both the 
systemic and pulmonary blood, in their returning currents, encountered an 
obstacle to their entrance into the ventricle. The result of this must have 
been a congestion of both systems, the signs of which, during life, were — a 
violet colour of the skin deepened by efforts in crying, difficult respiration, 
tumultuous and irregular movements of the heart, and anasarca of the abdo- 
minal parietes and the lower extremities. This child lived for three months 
and 23 days.t 

6lh and 7th. These two cases are introduced here on account of their 
being instances of the anomalous origin of the pulmonary artery, it being 
given off in both by the aorta. But they are examples also of slight con- 
traction of that vessel, it being in one ^^ of an inch less in circumference 
than the aorta, and in the other its branches, as well as the pulmonary veins, 
were only one-half their usual size. The pathological influence of this 
contraction of the pulmonary artery could not have been other than that 
which would have been induced, had it arisen as usual from the right ven- 
tricle. The heart, in both these instances, consisted of only two cavities, an 

* Gintrac, p. 150. t Ibid., p. 173. 



40 Stille on Cyanosis, [July 

auricle and a ventricle. Cited before in this essay, the Jirst of these cases 
was adduced to show the great disproportion that existed between the degree 
in which the blood was mingled, and that of the discoloration, which 
amounted merely to a lividity of the lips, apparent on the day of the birth 
of the child, and the seventh day afterward, when it died.* In the other 
case the discoloration seems to have been more diffused, the difference 
being referable to the greater diminution in the calibre of the pulmonary 
vesseis.f 

8th. This case has also been cited before for the same purpose as the first of 
the two preceding, (page 30). The pulmonary branches received their blood 
only after it had first passed through the aorta. This vessel held, therefore, the 
same relation to them as a pulmonary artery, and would have fulfilled the same 
office for them, in a degree compatible, perhaps, with a more extended term 
of existence than that which the patient attained, had it not been so con- 
tracted at its origin as materially to interfere with its own proper functions, 
as well as to keep back a proper supply of blood from the lungs. The dis- 
coloration was, as stated before, slight and remitting. 

9th. The last of the cases which we proposed to examine, is that in 
which it is stated that the pulmonary artery was absent, but its place sup- 
plied by bronchial arteries. The meagreness of the details furnished in the 
report of this case, and the ambiguity of some of ihem, may possibly lead us 
into erroneous deductions. We cannot, however, believe that the arteries 
here referred to under the name of bronchial, were those usually given off 
by the descending aorta; for this supposition is not required by a rational 
construction of the language used, nor is at all compatible with the fact of 
the individual who is the subject of the report having reached the age of 
16 years, as there stated. We presume that the word bronchial was em- 
ployed to denote the size and not the place of origin of the arteries spoken 
of, and that they might, with greater propriety, be termed pulmonary, and 
be considered as having been given off at the arch of the aorta. If this 
view be correct the case is similar to the one immediately preceding, in 
which the aorta is said to have given off two pulmonary branches, and the 
partial discoloration of the skin is equally explicable by the anatomical con- 
dition. | As the aorta arose from both ventricles, and therefore transmitted 
blood of a mixed character, this case has been before 9ited with reference to 
that fact, (page 30.) 

In order to avoid fatiguing repetition, it has been our endeavour, in the 
notice of these cases, to be as brief as was consistent with a correct apprecia- 
tion of their individual peculiarities. It is hardly necessary to revert in the 
present place to the necessity that called for their examination. It will be 
remembered that, having in a previous part of this article examined, by 
means of the cases we had collected, the doctrine which ascribed cyanosis- to 

* Gintrac, p. 44. t Ibid., p. 56. 

t Lond. Med. and Phys. Journ., vol. vi. p. 548. 



1844.] Stille on Cyanosis, 41 

a mixture of the venous with the arterial blood, it was considered that there 
was adequate proof of its invalidity; in looking, therefore, for some lesion 
which should be an invariable coincident of cyanosis, and at the same time, 
an efficient cause of its production, it was found that the contraction of the 
pulmonary artery was so constant in its occurrence that the few cases in 
which it was not found might, perhaps, upon examination, be discovered to 
act upon similar principles in the causation of the ordinary phenomena of 
the disease. The nine cases which we have just examined, were the only 
ones in which the pulmonary artery was not contracted, obstructed, or 
impervious. But in nearly all of them much more important alterations of 
structure than a mere contraction of the pulmonary artery were found to 
exist, and it was then necessary to examine whether the conditions pre- 
sented by them were such as were capable of producing venous congestion, 
or, in other words, of operating on the same principle as did the contraction 
of the pulmonary artery. 

It will now be seen, that so far from affording any ground for an objection 
to the doctrine that the essential characteristics of cyanosis are constituted by 
general venous congestion, they do on the contrary confirm it, and prove that 
there is no one lesion which is entitled to be considered as the anatomical 
character of cyanosis, but that it depends simply upon any cause which, 
acting at the centre of the circulation, will produce a stasis of venous blood 
in the capillary system. Cases of cyanosis, therefore, may be met with in 
which no one of the anatomical dispositions above enumerated shall be 
found; or, again, the lesion upon which the disease may really depend, shall 
be so recondite as to elude observation; but as it is evident that the variety 
of malformations and alterations of structure may be almost without limit, 
and that many more than those we have been able to gather may be pro- 
ductive of congestion, such instances will, probably, only bring additional 
proof of the correctness of the conclusions that previous facts have afforded. 
We are now prepared to state that the second requirement that was proposed 
as necessary for the establishment of any theory of cyanosis, is fulfilled by 
the facts that have been adduced, viz. 

2d. That the alleged cause shall be found in every case of cyanosis, or if 
not, there shall exist in its place some cause acting upon similar principles. 

It will be seen that the next requirement, viz : 

3r/. That the alleged cause shall never he found without the concurrence 
of cyanosis, is met by the same facts which were brought forward under the 
preceding head. We have found, in fact, no one case of contraction, obstruc- 
tion or imperforation of the pulmonary artery in which there was not cyanosis. 

If contraction of the pulmonary artery be now taken as the type of all 
the lesions that may produce a cyanosis, we are entitled to state, 

1st. Tliat it is present in every case of cyanosis. 

2d. That it never exists loithout the concurrence of cyanosis; and 

4* 



42 Stille on Cyanosis. [July 

3i. That it is an adequate explanation of the most important phenomena 
of the disease. 

The question has been agitated, and mostly in a speculative manner, whe- 
ther or not the contraction and obstruction of the pulmonary artery were 
congenital lesions. As it has been previously stated that in all the cases of 
cyanosis which we had collected, this lesion was uniformly found (9 cases 
excepted, in which for the most part, there was a malformation of the heart), 
it is hardly necessary to add, that in all those which were congenital, either 
contraction or partial or complete obstruction must have existed from birth. 
In order, however, that direct evidence on this point may not be wanting, 
the following statement is subjoined. 

In 28 cases of congenital cyanosis the pulmonary artery was contracted, 
obstructed, or impervious. 

It was found to be impervious at its orifice, or contracted and obstructed, 
in those who died at the following ages : 

Impervious in 1 at 7 days. Contracted or obstructed in 1 at 6 years. 

1 at 13 days. 3 at 8 " 

1 at 23 days ^ I at 9 " 

1 at 5 weeks. 2 at 10 " 

1 at 6 weeks. 2 at 11 '» 

1 at 8 months. 1 at 14 " 

1 at 11 months. 2 at 16 " 

1 at 15 months. 1 at 17 " 

1 at 1 year. 1 at 18 " 

Contracted or obstructed in 1 at 5 months. 1 at 29 " 

/ 1 at 5 years. 1 at 57 " 

A few facts in regard to the relative proportion of the two sexes which 
were the subjects of cyanosis, the number of cases in which it was conge- 
nital, and the duration of life, may here be added. 

Of 72 cases of cyanosis in which the sex was mentioned, 41 were male, 
31 female; of 71 cases in which the date of the attack was observed, it was 
congenital in 40, and occurred in the remaining 31 non-congenital cases at 
various periods after birth. 

The following table will show the duration of the disease in all the con- 
genital cases. 

7 patients died within 23 days after birth. 

3 " " between 23 days and 10 weeks. 

7 " " " 10 weeks and 1 year. 

10 " " " 1 year and 10 years. 

10 " " '* 10 years atid 20 years. 

1 patient " at 29 years. 

1 " " " 35 " 

I it u u 57 a 

It having been the sole object of the present inquiry, to ascertain the laws 
of the causation of cyanosis, and at the same time, Jo do this in a manner 



1844.] W. L. Atlee's Case of Extirpation of Ovarian Cyst. 43 

which, while it precluded speculative discussion, should place the results 
obtained upon a basis furnished by statistical evidence, it does not come 
within its proper scope to notice those other phenomena of the disease, 
which, although usually embraced in its description, are yet not to be 
deemed its essential constituents. Direct and decisive proof has been through- 
out insisted upon, and such the points alluded to are not capable of receiving. 
The writer will be amply repaid for the labour expended in the collection 
and preparation of the cases requisite for the foregoing investigation, if the 
results derived from them shall in any degree contribute to the furtherance of 
exact and useful medical knowledge. 



Art. III. — Case of Extirpation of a Bilocular Ovarian Cyst hy the large 
Peritoneal Section. By Washington L. Atlee, M.D., of Lancaster, 
Penn., Professor of Medical Chemistry in the Medical Department of 
Pennsylvania College, Philadelphia. Read before "the Lancaster City 
and County Medical Society," April 17th, 1844. 

December 13th, 1843, 1 was requested by Dr. Adam Shellar, of Mountjoy^ 
to visit Mrs. S., of Chicques, for the purpose of performing paracentesis 
abdominis in "dropsy of the abdomen." A mere glance at the abdomen 
induced me to doubt the existence of peritoneal dropsy, and upon a close 
examination I was fully satisfied that there was encysted or ovarian dropsy* 
As Dr. Nathaniel Watson, one of the attending physicians, was not present, 
and as the case would probably prove to be of more importance than had 
been anticipated, I proposed to postpone the operation until the 15th, in 
order that both the medical gentlemen might be present at the time of de- 
ciding upon the character of the disease by tapping. 

Accordingly, upon the 15th, I again visited the patient, and received the 
following history from her: 

She was 61 years old on the 26th of last November, never had had any 
children, did not believe she had ever conceived, had menstruated regu- 
larly in early life, and passed through her menstrual period at the age of 40 
years, without any untoward symptoms. For four or five years she felt a 
fulness in the lower part of the abdomen, which has gradually increased 
until the present time. Her attention had first been called to the enlarge- 
ment of the abdomen by a soreness there, which made it painful when 
she came suddenly against any object. How long she may have been 
swelled before this she does not know, but believes not long. About this 
period, and since, she frequently complained of pain in her right side, and 
would suddenly press with her open hand just above the hip bone. Before 
noticing the swelling she became very much constipated, and has continued 
so ever since, having recourse to small doses of Epsom salts as a daily laxa- 



44 W. L. Atlee's Case of Extirpation of Ovarian Cyst. [July 

tive. The process of defecation is difficult, and accompanied with the sen- 
sation of a mechanical obstruction. The faeces, however, are round, but 
contracted in size. From the earliest period of constipation there has always 
been, also, a more or less frequent desire to pass urine. About the same 
time her left leg began to swell, the swelling having continued ever since, 
and the right thigh above, and in front, has been affected with neuralgic 
pains. For years she has been troubled with occasional slight attacks of 
hepatic derangement, which were readily relieved by mild mercurials. For 
many years also she had a constant herpetic eruption on her left leg, which 
became better about the time the dropsy commenced, although a scaly con- 
dition of the skin has continued. She was peculiarly susceptible to the 
operation of medicine, and she possessed a constitutional idiosyncrasy to the 
action of mercury, becoming salivated by a single application of a mercurial 
solution to the skin. She can lie better upon her right side than upon the 
left. One day, in the early part of November last, in a certain position of 
her body, she felt something roll or fluctuate in the abdomen, communicating 
the sensation of a fluid. Frequently during exercise her respiration became 
slighfly accelerated, only however for a short time. This disturbance of 
the respiration she attributed to flatulency, to which she had been accus- 
tomed for years. Occasionally she felt a slight pain in the region of the 
uterus. Her appetite in general was good, but she required the observance 
of great care in diet, using the mildest nourishment for several years. 

The following notes, which were taken at the bedside of the patient, were 
dictated to Dr. Shellar as the examination was being made by myself. 

Pulse 88,* soft, open and full; skin soft and pleasant to the touch; tempe- 
rature natural and uniform; tongue slighfly furred, whitish, soft, moist, and 
spreading, the follicles at its root enlarged; ptyalism, caused by a few doses 
of mercurials during the last week. 

The patient lying on her back. The tumour of the abdomen is very 
prominent and nearly globular. Its greatest diameter extends from the left 
hypochondrium to the right iliac region. Below it is most prominent upon 
the right side, above it is most prominent upon the left, elevating consider- 
ably the cartilages of the ribs on that side. The lower edge of the thorax 
forms the upper boundary of the tumour, and is elevated by the latter. The 
tumour is softest upon the right side, most resisting upon the left. The 
sound, on percussion, is flat over the whole anterior face of the abdomen, 
even in the epigastrium and hypogastrium. By the hand a pulsation can be 
felt throughout the whole body of the tumour; by the stethoscope the 
impulse and sound of the aorta can be recognized over the whole tumour, 
but most strongly over the left side. The integuments of the abdomen are 
smooth and natural in appearance. The size is rather larger than at the full 
period of pregnancy; there is greater width, more prominence above the 
umbilicus, and rather more flatness in the most anterior part of the tumour. 

The patient lying upon her left side. The change of position does not 
alter the appearance and contour of the tumour. The sound is flat in the 
whole lumbar region of the right side; tympanitic in the right hypochondriac 
region. Fluctuation in the right side is tolerably distinct. 

The patient lying on her right side. There is no change in the tumour. 
The elevation of the left side when lying on the right, is greater than that of 
the right side when lying on the left. Tympanitic sound in the left lumbar 

* On the 13th the pulse had been 80; it probably was now excited by the idea of 
paracentesis. 



1844.] W. L. Atlee's Case of Extirpation of Ovarian Cyst, 45 

region merely distinguishable, but distinct in the left hypochondriac region. 
Fluctuation perceptible on the left side, but not so distinctly as on the right. 

Examination per vaginam. The vagina is considerably shortened ; a 
tumour can be felt through its posterior wall, having an extremely tender 
spot high upon its anterior face when pressed upon with the point of the 
finger backwards. The supposed cervix uteri is thrown forward behind the 
symphysis pubis, puffy, tumefied, but free from tenderness; the os tincae is 
not evident. 

Examination per anum. As soon as the finger enters the sphincter it 
strikes against a tumour, which is felt through the anterior walls of the 
rectum, and appears to be globular and very slightly uneven. It is movable 
and has a sarcomatous feel. 

Previously to paracentesis the abdomen was again examined in reference 

to a proper point to introduce the trocar, the patient being on her back. 

By pressure over the abdomen a resisting body could be discovered parallel 

to the linea alba, about an inch or an inch and a half to the left of it, and 

along its greatest length. In order to detect this it was necessary to make 

very deep pressure, and it felt like a solid tumour dipping down under the 

linea alba towards the riffht side. Over the rio^ht side there was distinct 

/-I • 

fluctuation; over the left and also across the abdomen the fluctuation was 

indistinct. In consequence of these circumstances a point, about two inches 
to the right of the mesian line, and midway between the umbilicus and 
pubis, was selected for tapping. The trocar entered without using much 
force, and seven pints of lemon-coloured, very clear transparent fluid, 
of the consistence of serum, were drawn out. The abdominal tumour, 
however, only diminished on the right side, leaving the intumescence of the 
left side equally as great as it had been before tapping. Now, upon exa- 
mining the abdomen again, the tumour, still existing within the left side, can 
be traced across the linea alba projecting deeply into the right side to the 
extent of three or four inches across the mesian line, having upon its deep 
surface loose longitudinal ridges, supposed to be folds of the flaccid sac just 
emptied. Fluctuation of the left side is now much more distinct than it 
was before, extending even into the deep portion of the tumour upon the 
right side. The aortic impulse is not so evident as before. This tumour 
evidently is a sac, and the appearance of solidity along the left of the linea 
alba, previous to paracentesis, was owing to the right sac having overlaid 
the left sac to a point beyond the linea alba, perhaps about two inches or 
more, thus making a superficial layer of fluid over the body of the left sac, 
through which the latter, upon deep pressure, simulated a deeply seated solid 
tumour. A ridge is also perceptible upon the left side of ibe linea alba, 
formed, no doubt, by the empty sac being folded upon the septum of the 
two sacs. 

In consequence of this ridge a point, about two inches to the left of the 
linea alba, was selected for paracentesis of the left sac. It required more 
force to introduce the trocar than in the first instance. After making one 
plunge with the trocar, I had to follow it with another before it entered, 
and after it had entered the fluid did not flow freely through the canula; it 
appeared as if a portion of membrane was lying against the inner opening 
acting as a valve. From this circumstance I believe I must have first pene- 
trated the overlapping layer of the right sac before entering the left, and that 
the left was only partially entered by the canula. However, upon intro- 
ducing through the canula a flexible female catheter, which went in without 
opposition, a lemon-coloured slighfly cloudy fluid, of the consistence of 



46 W. L. Atlee's Case of Extirpation of Ovarian Cyst. [Ju^y 

serum, escaped through the catheter and around it through the canula. It 
nmounted to ten pints. The whole extent of the abdomen was now dimi- 
nished in size, and upon handling it an undulating vibrating motion was 
produced, as if some fluid still existed in the cavities, although all the usual 
ejETorts had been used to remove the whole of it. 

The fluid from both cavities had an adhesive feel between the fingers, and 
when boiled was hardened like the white of an egg, so that the spoon con- 
taining it could be knocked, while inverted, against the table without dis- 
placing it. The fluid of the right sac, when shaken in a vial, formed a very 
adhesive bead, which continued a great length of time, while the fluid in the 
left sac formed a volatile bead, which disappeared directly. It did not aflect 
litmus paper. 

The urine, passed before tapping, was not coagulated by heat; it reddened 
litmus paper strongly. 

Half an hour after tapping the pulse was 80, and in other respects the 
patient was the same as before. 

After dinner, at 1 o'clock, when the patient had recovered from the fatigue 
of the operation, the examination was resumed, she lying upon her back. 
Longitudinal ridges can be felt upon the right side of the spine in the lumbar 
region. They are very movable, and supposed to be the folds of the flaccid 
cysts along the posterior part of the septum. The sound, on percussion, is 
distinctly tympanitic in the epigastric, right hypochondriac, umbilical and 
right lumbar regions, less so in the left hypochondrium, rather flat in the left 
lumbar, and flat over the whole lower part of the abdomen. Percussion 
over the ridges on the right side is painful when the pleximeter is accom- 
panied with deep pressure. 

The patient lying on her left side, and examination per vaginam. The 
part, previously supposed to be the enlarged cervix uteri, is now considered 
to be the uterus itself in a state of atrophy. It now occupies a position 
nearer to the sacrum than to the symphysis pubis, and more to the left side. 
A hard, globular tumour is felt through the posterior wall of the vagina; 
passing the finger under it I can elevate it above the brim of the pelvis, so 
as to feel it with my other hand placed over the right groin. While poising 
the tumour upon my finger in the vagina, and pressing with the fingers of my 
other hand into the pelvis from above the pubis, I can get beneath the tumour 
so as to elevate it considerably. The attachment to the right side of the 
uterus can be easily distinguished by pressing it between the finger within 
and the hand outside. This attachment is apparently very short, owing 
probably to the tumour being jammed against the uterus. No other attach- 
ments can be recojjnized. On the left side of the uterus nothino; unusual is 
discovered in the pelvis. 

Examination per anum. The finger again meets the tumour immediately 
within the sphincter lying against the anterior wall of the rectum. With the 
finger in this position, and the other hand on the right groin, the tumour can 
be^played up and down, and seems less sensitive to pressure than before 
paracentesis. When the tumour is in situ the rectum is pressed flat against 
the curve of the sacrum. Hardened /?«^ faeces are discovered in the rectum. 

The tumour is considered to be an enlargement of the right ovary, asso- 
ciated with ovarian cysts. The left ovary is supposed to be free from 
disease. 

Having now fully satisfied myself of the character of the disease, it 
became my duty to inform the patient of its probable results. I told her 
that the records of medical experience, as well as my own observation, fail 



1844.] W. L. Atlee's Case of Extirpation of Ovarian Cyst. 47 

to render any assurance of the least prospect of cure by ordinary means— 
that ovarian dropsy is beyond the reach of medicine — that the disease, most 
likely, would never be less burlhensome than it is now — that sooner or later 
it would cause death — that persons with the same disease had sometimes 
lived many years, but that at her age, and with her constitution and amount 
of suffering, this most probably would not be the case with her— that tapping 
would afford temporary relief, and that the oftener it was done the oftener 
and sooner it would have to be repeated, and thus by rapidly draining the 
system the sooner it would destroy life — that operations for the entire extir- ^ 
pation of the diseased mass had been performed, some terminating success- 
fully, others fatally — that it was an operation of the greatest magnitude, and 
was not considered a legitimate or justifiable one by many eminent medical 
men — and that death might occur as its immediate or remote effects. On 
the other hand, I informed her, that an operation, although fraught with 
danger, afforded the only means of restoration to health — that, although her 
advanced age lessened, in some degree, the chances of recovery, yet I 
believed she had stamina of constitution sufficient to bear an operation — that 
I desired her and her friends to clearly understand me as not urging it upon 
her, or advising her to it — that after having duly and deliberately viewed the 
matter in all its aspects, she must decide for herself — that if she then deter- 
mined to risk the operation rather than suffer her disease, I would undertake it, 
provided the services of a good nurse could be procured, and an experienced 
surgeon would share the responsibility of the case with me. 

This statement having been made to my patient in the presence of her 
husband, her sister, and the attending physician, with a spirit of candour 
and frankness, I took my leave of her, promising to render my assistance in 
any way, and at any time it might be desired. 

A letter from Dr. Shellar, dated December 22d, states that "Mrs. S. is 
doing quite well, her pulse ranging from 75 to 80, there being no febrile 
excitement. She sits up in bed, has not walked about, says she feels weak 
when on her feet. I measured her day after day, and so far find very little 
difference." 

March 7th, 1844, I was requested to visit Mrs. S. in order to tap her 
again. She informed me that for six weeks after her first tapping she felt 
pretty comfortable, but the fluid began to accumulate soon after I left her. 
She now feels much worse and much more oppressed than she did before 
the first tapping. She has to make water frequently, and passes only a 
little at a time; has, however, no occasion to rise out of bed at night to 
urinate, and can pass water with greater ease standing than she can in a 
stooping posture. She still has to resort to laxatives to procure stool, and 
defecation is difficult, and accompanied by a sensation of obstruction. Any 
kind of exertion, as getting into bed, overcomes her, and produces difficulty 
of respiration. Her left leg is considerably cedematous, the other less so. 
She complains of a peculiar forcing and pressing uneasiness and pain in the 
left hypochondriura. 

After giving this account of herself she told me that she had concluded to 
have the operation performed, if I believed her capable of living through it, 
as she suffered so much from the disease that she felt satisfied, if not relieved, 
she must soon sink under it. Her friends were surprised at this announce- 
ment, as she had never spoken of the operation to any one until that mo- 
ment, and from her silence all had concluded that she had no idea of it, 
althoutrh she had arrived at that determination some time before. I therefore 



48 W. L. Atlee's Case of Extirpation of Ovarian Cyst. [July 

conducted the examination with particular care, and reported, as I proceeded 
in it, to Dr. Shellar, who wrote it down as before. 

Soon after my arrival to-day her pulse, while she was sitting, was 100. 

The patient lying upon her back in bed. The abdominal tumour is larger 
than at the first examination; its contour the same, rather more prominence 
in the inferior right side. Admeasurement of the abdomen, taken obliquely 
around it from the left hypochondrium to the right lumbar region, is forty and a 
quarter inches: from the right hypochondrium to the left lumbar region, thirty- 
seven and a half inches; and transversely around the belly above the hips, 
thirty-eight inches. Percussion of the abdomen is accompanied by th« same 
sounds as before. A ridge can be felt and seen along the left of the linea 
alba, supposed to be the septum of the sacs. There is less pain on pressure 
around the umbilicus than before the first tapping. The patient says that 
after she was tapped there were pain and tenderness on sneezing or coughing 
along the left side of the mesian line, extending above and below the umbi- 
licus three or four inches. This has continued ever since. 

Examination per vaginam. The cervix uteri is slightly tumefied and 
pushed down nearly in contact with the perineum, and to the left of the 
central line. The pelvis is nearly filled with a resisting substance, the 
greatest resistance being on the right side. A hard globular body can be 
felt through the posterior wall of the vagina, resting against the concavity 
and point of the os coccygis. The uterus is pretty firmly fixed in its posi- 
tion, it being scarcely movable. There is no particular tenderness observable 
in touching the uterus. 

The patient being turned upon her left side it makes no change in the con- 
dition of things. 

Examination per rectum. A hard globular body is felt as soon as the 
finger enters the internal sphincter, pressing against the anterior wall of the 
gut, and carrying the latter before it so as to convert that part of the rectum 
into an inverted sac for its reception : the tumour projects into the rectum as 
if it were a tumour of the gut itself arising from its internal face. The 
point of the finger passed up and around its left border to its anterior face, 
meets an exceedingly tender point, which causes the patient to flinch sud- 
denly and exclaim that the pain flies to her very heart. The tumour presses 
the walls of the rectum together, occupying the hollow of the sacrum and 
coccyx, and pressing pretty firmly against them, and feels like sarcoma. 
High up on the posterior part of the tumour, along the track of the rectum, 
it is very tender to the touch. The patient says she suflfers more from this 
examination than from the one before. 

T now punctured the sac on the right side, and took from it twelve and a 
half pints of the same clear, straw-coloured, serum-like fluid as before, 
making the puncture through the old cicatrix. From the left sac, which was 
opened about an inch to the left of the old mark, in order to avoid the over- 
lapping sac, I removed eight and a half pints of fluid similar to the above, it 
being much clearer than the fluid out of the same sac at its first tapping. 

After paracentesis she measures around the hips transversely thirty and a 
quarter inches; above the hips and umbilicus twenty-six and a half inches. 
In examining the abdomen I can distincfly grasp the aorta and trace it to its 
bifurcation, can feel the projection of the os sacrum, and the folds of the 
flaccid cysts, and also a singular, lobulated, oblong tumour crossing the 
mesian line below the projection of the sacrum, deeply seated, and inclining 
most to the left side. This tumour is supposed to be either the aggregated 
folds of the sacs, the development of other cysts or indurated deposits in 



1844.] W» L. Atlee's Case of Extirpation of Ovarian Cyst, 49 

in the septum, or hardened faeces in the intestines. It is quite movable, and 
can easily be grasped in the fingers. 

Examination per vaginam. Employing the finger gently, and without 
much pressure, the parts within the vagina appear very much the same as 
before tapping. The uterus is quite movable, can be played up and down 
between the finger in the vagina and the hand above the pubis. The tumour, 
posterior to the vagina, can be dislodged and elevated to- the right side 
against the hand over the right iliac region. While keeping the tumour 
thus poised upon the finger in the vagina, and endeavouring, with the other 
hand, to get under the tumour above the brim of the pelvis outside, a very 
tender spot is encountered, which produces the same intense sufi'ering as in 
the examination per rectum, and, no doubt, is owing to the same part of the 
tumour being touched. The tumour is very movable, and can be played up 
and down within the pelvis. While the tumour is elevated the pelvis seems 
empty. I think the tumour has enlarged since the first examination. The 
posterior face of the uterus is slightly tender. No abnormal condition can 
be detected on the left side of the uterus. 

The patient having been turned upon her left side, no change is produced 
in the relative position of things. 

Examination per rectum. The attachment of the tumour to the uterus 
can be pretty distinctly traced with the finger, in the rectum, placed against 
the posterior wall of the broad ligament, and the fingers of the other hand 
outside pressed deeply into the pelvis against its anterior wall, thus grasping, 
between them, the broad ligament. The attachment, thus examined, is sup- 
posed to be more than an inch in extent, and the tumour is quite movable 
upon it. 

From the whole examination, I think that the morbid attachments, if any, 
of the sacs and tumour are very slight. 

After she had recovered from the exhaustion produced by the tapping, 
about one hour having elapsed, her pulse was 88. 

I again reviewed the symptoms and history of the case, and felt confident 
that it was a case of encysted ovarian dropsy; that there was a tumour of 
the right ovary; that the cysts were connected with this tumour, though they 
possibly might originate in the left ovary ; but that there was no evidence 
leading to the opinion that the left ovary was diseased. 

As my patient had now determined upon the operation, I emphatically 
repeated to her and her friends all I had before told her, and in addition 
insisted upon having the privilege of selecting a consulting surgeon to 
examine the case, and also share in its responsibility, should he coincide 
with me in opinion. Accordingly, on the 9th of March I called my brother, 
Dr. John L. Allee, into consultation, and visited Mrs. S. in company with him 
and Dr. Shellar. 

In addition to the history already given, she stated that about four years 
ago, while riding on horseback with a basket of marketing before her upon 
her arm, she felt pain of the abdomen from the pressure of the basket. She 
became larger on the right side first, and had several times called the atten- 
tion of her husband to the circumstance. Ever since the first tapping she 
can lie best upon the left side. After both tappings, before much fluid had 
accumulated, she could pass faeces without much difficulty. The oedema of 
the lower extremities, which existed before lapping, always diminished after- 
wards. Until recently there had not been much disturbance of the general 
health, although her constitution, for the last fifteen years, had been feeble. 

To-day the abdomen is very much relaxed, and much more tender to 
No. XV.— July, 1844. 5 



50 W. L. Atlee's Case of Extirpation of Ovarian Cyst. [July 

pressure than hitherto, particularly in the right iliac region. From the 
umbilicus downwards it seems to be occupied by a thick membrane or sac, 
which gives a dull sound on percussion, the upper border being occupied by 
a hard tumour about four inches long, and one and a half or two inches wide, 
lying transversely across the abdomen. This tumour is movable, and appears 
to have no connections with the uterus, and is the same tumour much in- 
creased in size, which I observed for the first time day before yesterday. 
Above this point, and also in the right iliac region, the sound is tympanitic. 
Her pulse is 78; the tongue is very slightly coated with a yellowish fur, but 
looks healthy; her appetite is good, and has been rather craving since last 
summer. 

My brother, having made a careful examination per vaginam et anum, 
arrived precisely at the same conclusion that I had done: that the dropsy 
was encysted; that the cysts and tumours were developed in the right ova- 
rium ; that the uterus was slightly atrophied, was distinct from the diseased 
ovarium, except by its natural connections; that the pedicle was nearly or 
quite the normal length; and that no important adhesions existed. My 
brother fully concurred with me also in considering the operation a justifi- 
able one, if the patient chose to have it performed. She then informed us 
that she had come to the conclusion herself of having the tumour extirpated; 
that she felt sensibly that her health had recently rapidly declined, and her 
sufferings were increased; that she had considered all the dangers of the 
operation, and desired to have it performed whenever we should deem it 
advisable. The opinion which I had previously given to her, was now 
jointly delivered again to her in the presence of her husband and sister, and 
the dangers of the operation fairly stated and fully understood by all the 
parties interested. It was then determined to wait until the cysts should 
become partially filled, so that the distended sacs might in some measure 
afford a guide to us in the operation. In the mean time she was ordered to 
take regular and moderate exercise, and to use nourishing light diet and mild 
laxatives. 

March 2od, my brother and myself again visited Mrs. S., in company 
with Dr. Shellar. For several days after our last visit her health had not 
been good; she had had considerable fever, with great tenderness of the 
abdomen, and there was quite a hardness around the wound made by tap- 
ping, on the right side, from which, after removing the adhesive strip which 
covered it, a good deal of healthy pus was discharged, which afforded her 
great relief. After this the fever left her, the sore began to heal, and her 
health to improve, though the tumours continued tender, and the water 
rapidly accumulated in the sacs. 

The abdomen is already quite prominent, and elevated to the distance of 
two inches above the umbilicus. The tumour which we felt in the inferior 
part of the abdomen, now occupies the left hypochondriac region anteriorly, 
and is tender upon pressure: it appears to be connected with the walls of 
the sacs, and to have become elevated as they became distended. The 
parietes of the abdomen can be pinched up from the sacs, and moved freely 
over their surface, even at the points where the sacs had been punctured, 
indicating freedom from attachments. The abscess spoken of above must 
have been confined to the walls of the abdomen. The patient's pulse is 90, 
and her health tolerably good. 

We fixed upon Friday following, the 29th inst., for extirpating the dis- 
eased mass. She was ordered to continue her usual diet until Thursday 
morning, then to take a full dose of her laxative medicine, after which she. 



1844.] W. L. Atlee's Case of Extirpation of Ovarian Cyst. 51 

was to take nothing but barley water, and in the evening a few drops of 
elixir of opium, to quiet the peristaltic action of the bowels. 

March 29th. Friday, 10 o'clock, A. M.; the patient's pulse is 86, soft, 
and compressible; skin soft and natural; tongue slightly red, but moist, and 
having a thin yellowish fur on its middle and posterior part. She had taken a 
dose of Epsom salts yesterday morning, which fully evacuated her bowels, 
after which she took ten drops of M'Munn's elixir of opium last evening, and 
slept pretty well nearly all night. After taking the salts she was restricted to 
barley water as her only nourishment. This morning she had a small liquid 
discharge from her bowels resembling barley water. The last time, previ- 
ously to the operation, she passed her water, was between 9 and 10 o'clock, 
A. M., to the amount of a teacupful, which was an unusually large quantity 
for her to make at once. It reddened litmus paper. 

Preparatory to the operation, all who were to be engaged in the manipula- 
tion of the abdomen, carefully trimmed their nails, and washed their hands, 
and every arrangement was made by my brother and myself previously to 
admitting the other medical gentlemen into the room. Tlie patient was very 
comfortably fixed upon an ordinary dining table, with the leaves down, her 
head and shoulders were slightly raised and resting on pillows, and her feet 
supported upon two chairs at the lower end of the table, her hips being near 
the end, and covered by a sheet applied as a child's diaper; a sheet was 
thrown over her lower extremities, and an ordinary night-gown enveloped 
her body. The hair along the mesian line of the abdomen, and over the 
pubis, was shaved off, and the parts cleanly sponged and dried. The abdo- 
men presented an enlargement equal to that usually found in the seventh 
month of pregnancy, wanting, however, its symmetry, since the tumour 
principally occupied the left side. 

All the preparations being completed, and the patient's mind being as 
calm and tranquil as could be desired under the circumstances, the medical 
attendants were called into the room, and at the same moment a light cambric 
handkerchief was thrown loosely over the patient's face. 

I took my position upon the right side of the patient, my brother, as 
principal assistant, being on the left, and in the presence of Professor D. 
Gilbert, Drs. Shellar, Stubbs, Gryder, Carpenter, and Cox, respectable phy- 
sicians, and Messrs. Richards, Rohrer, Hershey, and Franklin, medical 
students, and one female attendant, I commenced the operation at eleven 
minutes past 11 o'clock, A. M., the patient not being in any way secured 
or fastened, excepting her knees and hands supported by the physicians 
present. 

I began the incision with a scalpel, immediately below the umbilicus, and 
carried it down in a straight line to within one inch of the symphysis pubis, 
making a bold section through the skin and subcutaneous tissues, until I 
struck upon the sheath of the recti muscles. The adipose tissue was unusu- 
ally abundant for so lean a patient. In deepening the incision about the 
centre of the section, the inner edge of the right rectus muscle was pene- 
trated, in consequence of having been drawn over towards the left side by 
the greater prominence of the tumour in that direction. A small incision 
was now made through the linea alba and peritoneum, through which I 
introduced the probe-pointed bistoury, and slit them open to the extent of 
the external wound. The patient did not evince any pain until this section 
of the peritoneum was being made. A small branch of the epigastric artery 
was wounded just below the umbilicus, and another just above the pubis, 
requiring no ligature. As soon as the peritoneum was opened, a large white 



52 W, L. Alice's Case of Extirpation of Ovarian Cyst. [J»ly 

dense sac, studded with dendriform clusters of capillary vessels, rode up 
against the opening. I now introduced my hand into the abdominal cavity 
for the purpose of examining the connections of the tumour, and of lifting 
it out of its bed. The contact of the hand against the internal face of the 
peritoneum produced considerable pain. Carrying my hand up the right 
side of the tumour, and over its fundus, which projected into the epigastric 
region, I discovered no adhesions until I arrived into the lower part of the 
left hypochondriac region, where I came against a ligamentous band, which 
could be traced in a continuous sheet along the left side down into the pelvis. 
Now endeavouring, with my hand behind the tumour, to tilt it out of the 
abdomen, I found the opening entirely too small to permit this, and as there 
was no effusion into the cavity of the peritoneum, and as I did not wish the 
contents of the sacs to escape therein, I preferred extending the incision 
both ways to diminishing the size of the tumour by puncturing the cysts, 
and thus also increasing the difficulties by rendering them flaccid. The 
incision below was continued to the bone, and above it was extended about 
three inches, rising above the umbilicus about two inches, and passing it on 
the left side, I was now enabled to seize the tumour with both hands, and 
by careful manipulation succeeded in rolling out the fundus of the tumour. 
The lower part of the tumour still seemed to be engaged in the pelvis, but 
by continuing gradual outward pressure, it suddenly arose from the pelvis 
with a sacking kind of sound distinctly audible. During this time there was 
no protrusion of the intestines, except a very small knuckle at the upper 
and right side of the tumour, which was easily pushed back by my brother's 
finger. I now carefully drew the tumour forward through the opening, and 
placing it into the hands of Dr. Gilbert, I turned it over upon the left side of 
the patient, in order to have a better opportunity of tying its pedicle, which 
we had supposed had originated from the right side of the uterus. The 
band previously detected upon the left side I considered extensive omental 
attachments, and as it bound down that side of the tumour very closely, I 
determined to secure the pedicle on the right side first, and afterwards evert- 
ing the tumour still more, I could more easily detach the rest. To our great 
disappointment, however, I found no connections whatever with the right side 
of the uterus. I now changed the position of the tumour from the left side 
of the patient over to the right side, thus putting on the stretch and exposing 
to view a broad ligamentous sheet, attaching the tumour to the body of the 
patient by a pedicle five or six inches broad, extending from the left hypo- 
chondrium down into the pelvis. Within this ligament the sigmoid flexure 
of the colon was incorporated, and near its upper border approximated to 
within an inch of the tumour. It was also highly vascular; one vein, as 
large as the largest size goose-quill, ran along the tumour where it was 
attached, and sent out large ramifications throughout its whole extent. 
These veins were very much engorged with dark-coloured blood. This 
pedicle consisted of a double fold of peritoneum arising out of the broad 
ligament of the uterus, having a triangular form; its lower edge, running 
from the uterus to the left side of the pelvis, was several inches long; its 
upper edge, running from the tumour to the uplifted sigmoid flexure, was 
one inch in length; and the distance along the tumour, between these two 
edges, as above stated, five or six inches long, having the fallopian tube very 
much elongated and somewhat attenuated, stretched up to the top of the 
tumour. A surgeon's needle, armed with a waxed single strand of saddler's 
silk, was now passed through so as to include about one inch of the lower 
border of the pedicle, and firmly tied. This portion of the pedicle was then 



1844.] W. L. Atlee's Case of Extirpation of Ovarian Cyst. 53 

divided near the tumour. This exposed some of the large veins upon its 
surface, which ruptured as soon as they were deprived of their peritoneal sup- 
port, and most of the blood lost in the operation was poured out at this stage 
of the dissection. A second single ligature was introduced about an inch 
above the first, embracing several large veins and the fallopian tube, but in 
endeavouring to tie it the ligature broke twice, after which I substituted a 
double strand of saddler's silk, and secured it well. About one-half of the 
pedicle remaining above, through which several engorged veins inosculated, 
it was transfixed in the centre with a needle doubly armed with a double 
strand of silk, which being secured below and above, the last being very 
near the tumour in order to avoid the intestine, the whole connection was 
then separated and the tumour removed. The amount of blood lost was 
not more than five or six ounces, which was found in the cavity of the 
pelvis. This was carefully removed, and the cavity well cleansed from all 
coagula and fluid blood, by soft sponges pressed out of warm water. The 
cut ends of the pedicle were carefully examined, and there was no oozing of 
blood. The ligatures, four in number, having been brought out at the lower 
end of the wound, the latter was now carefully closed by nine harelip sutures, 
and intervening adhesive strips, covered with patent lint, and a soft compress, 
and the whole secured by a broad towel, extending from the thorax to the 
trochanters, around the abdomen; and the patient was comfortably placed in 
bed at five minutes before 12 o'clock. 

During the operation the patient evinced comparatively little pain or suf- 
fering; indeed, at no time were there any manifestations of pain, except 
when the peritoneal lining of the abdominal parietes was touched. There 
was also some uneasiness noticed whenever the support to the tumour, after 
being dislodged, was in any way relaxed, so as to cause traction upon its 
attachment to the pedicle. By the time the tumour was removed the patient's 
pulse had fallen to 60. The respiration was not complained of, but seemed 
to be performed without the aid of the abdominal muscles. 

In consequence of the previous judicious treatment and regimen, the intes- 
tines lay in a perfectly collapsed or quiescent state, quite free from any 
peristaltic action, thereby enabling the operation to proceed without embar- 
rassment or difficulty being experienced from them. The intestines, how- 
ever, presented a darker pinkish appearance than in Miss R.'s case, owing 
to considerable venous congestion, as was evinced by an engorged state of 
the veins of the mesentery. The very favourable condition of the stomach 
from the same cause was also pre-eminently exemplified, by the complete 
absence, during the operation, of all gastric irritability — no nausea, vomiting, 
or other uneasiness being complained of, except a slight feeling of flatulent 
distension, unaccompanied by eructation, a small sense of thirst, and a feel- 
ing of weakness in tne first stage of the operation, which last, however, soon 
passed away. 

There was no chilliness or sinking complained of, but the hands became 
somewhat cool and relaxed. 

The omentum was crowded down into the left side of the pelvis, had quite 
a healthy aspect, and formed no attachments to the tumour. It was lifted 
from the pelvis, and before closing the wound, spread over the anterior face 
of the small intestines. The uterus was quite healthy in appearance, but 
considered to be slightly hypertrophied, and the right ovary was entirely 
free from disease. There were no attachments at the points where para- 
centesis had been performed; indeed, there were no connections whatever, 
excepting to the pedicle. 

5* 



54 W. L. Atlee's Case of Extirpation of Ovarian Cyst. [July 

While engaged in dressing the wound, the patient gave directions to the 
persons about her in a clear and strong voice. 

The operation, previously to dislocating the tumour, occupied six minutes, 
and eight minutes more until the tumour was removed, making fourteen 
minutes from the time the knife was laid upon the abdomen until the tumour 
was carried from the patient. 

At the commencement of the operation the temperature of the room was 
81°, and arose as the operation progressed to 86°. The out-door tempera- 
ture at 2 o'clock, P. M., was 61°. Wind N. W. in the morning, and changed 
to the E. afterwards. 

Before she was placed upon the table there were several eructations of 
wind from the stomach, and after she was placed upon the table, in raising 
her up to fix the pillows there was a slight eructation. 

Fifteen minutes after 12 o'clock her pulse was 56; her countenance 
slightly pale, but not sunken; the temperature of the skin very little lower 
than natural; voice clear and strong; she complains of dull, deep-seated pain 
in the lower and internal part of the abdomen, near the seat of the ligatures. 
Ten minutes after the pulse rose to 66. The patient is to be restricted to 
cold water, no nourishment. Is, P. M. Pulse 66; skin warmer, quite 
natural; tongue the same as before the operation; pain somewhat dimi- 
nished; no flatulence, hiccough, or nausea. 2 o'clock, P.M. Pulse 68; 
the patient complains of slight sickness of the stomach, which she attributes 
to flatulency, and can relieve herself by eructation. 2 hours 45 minutes. 
Wind more troublesome, a little belching, and feeling of sickness; describes 
the feeling as water-brash. 3 P. M. Pulse 70; stomach more settled, skin 
soft and of good temperature, and the patient quite comfortable. 3^, P. M. 
In a natural sleep. 4, P. M. Pulse 77, heat of skin increased, patient com- 
fortable. 7, P. M. Pulse 82, continues soft and compressible. Wind blow^- 
ing very strong from the east, and raining hard. 10, P. M. Pulse 84, rather 
more full and resisting; skin warmer, and she complains of the hands being 
too warm. The tongue has not altered in appearance, but becomes dry, 
which is usual with her while in a recumbent posture. 11 5, P. M. Drew 
off" a half pint of urine with the catheter, in order to prevent any action of 
the abdominal muscles by any voluntary efl'ort. It reddened litmus. 

From this time until 3 o'clock of Saturday morning, the 30th, her pulse 
ranged from 78 to 84, and was soft and compressible. At this time the pulse 
had very slight quickness and some fulness ; she had a transient flatulent 
pain, producing a little sickness. 6, A. M. The patient passed a very com- 
fortable night ; had no symptoms requiring attention; took a few spoonsful of 
water occasionally, and dozed a good deal; complained only of dryness of 
the mouth and heat of the hands. Wiped her hands with a wet cloth, which 
was very grateful to her. Felt a desire to have her bowels moved, which 
passed off" again. 9, A. M. Pulse has not risen above 84. Used the 
catheter; removed a half pint of healthy urine. Allowed the patient thin 
barley water. 2^, P. M. Pulse 85; a litUe quickness. Complains of her 
position; feels fatigued and sore. Had her shifted in a moderate degree ; 
felt pain over the abdomen on being moved. Some gastric disturbance from 
wind. 3, P. M. Pulse 86, moderately hard ; skin quite natural. Had a 
smart thunder gust with hail. 5, P. M. Pulse 84 ; complains of pain after 
drinking cold water. 6, P. M. Pulse 90 to 94, rather quick and full, but 
not hard ; palms and soles warm and rather dry; tongue slightly furred, 
somewhat dry, but not glazed; general surface of skin about natural; has 
passed no wind per rectum ; has had no real nausea, but a feeling of wind in 



1844.] W. L. Atlee's Case of Extirpation of Ovarian Cyst, 55 

the stomach, and a desire to raise it. Removed eight ounces of deep straw- 
coloured urine. Moderate pressure on the abdomen — gives no pain except in 
the left iliac region, and that is more soreness than sharp pain. 9, P. M. 
Pulse 98, harder ; tongue dry and furred; thirst increased ; skin hotter than 
natural ; tenderness on pressure over the whole abdomen, greater at the lower 
part. Dr. Cox, who remained with her at this time, bled her to the amount 
of about ten ounces, after which the pulse rose to 100, and became soft. 
10, P. M. Pulse 98, soft and much less quick; skin natural temperature; 
abdominal tenderness diminished ; stomach calm ; the patient prefers mode- 
rately cool water to barley water. 

Sunday, 31st, 1 o'clock, A. M. Pulse 95 ; upper part of abdomen slightly 
painful, lower part painful on pressure; inclined to doze; thirst not great. 

7, A. M. Puise 100; has not exceeded this. Dr. Shellar removed ten 
ounces of highly coloured acid urine, after which the pulse sunk to 90, soft; 
skin natural ; slight pain in the abdomen on coughing. Passed a pretty com- 
fortable night, and had some natural sleep, and dozed a good deal. The 
thermometer sunk to 22° last night, and the wind changed to the N. W. 
2, P. M. Pulse 102, soft, compressible; skin natural; tongue dry, but soft; 
no unusual fur; it appears perfectly natural after drinking; abdomen slightly 
distended, sound tympanitic ; no tenderness on pressure, except over the left 
groin ; drew off about four ounces of highly coloured urine. The patient 
was shifted from one side of the bed to the other without any manifestation 
of pain ; a disposition to rift up wind. As barley water sickens her, ordered 
her to take the water off of scalded bread or toast, and seasoned with salt. 
Took a teaspoonful of salts. 5, P. M. Pulse 105, harder; skin warmer, 
soft, and moderately moist; slight tenderness over the whole abdomen; the 
patient moans, relishes toast and water, and takes it freely, and it lies well on 
the stomach ; slight borborygmi. 7, P. M. Administered injection of flax- 
seed tea; tenderness of the abdomen diminished; pulse 106, compressible. 

8, P. M. Pulse 105, softer; injection operated about five minutes ago, had 
a fetid smell, and was accompanied with much wind; less heat of skin; 
scarcely any pain on pressure, except in the lower part of the abdomen. 
10, P. M. Pulse 103; has had quite a refreshing sleep; drew off five 
ounces of highly coloured urine. 11^, P. M, Pulse 102; has been sleeping; 
Dr. Shellar administered another injection of flaxseed tea, with five drops of 
elixir of opium in it; complains of water-brash directly after drinking; 
tosses about the arms, and draws up her knees occasionally. 12 o'clock. 
Pulse 100, soft; skin soft and natural; less dryness of hands ; lies perfecfly 
easy; is in a perfecfly natural sleep; very litfle tenderness of the abdomen. 

2 o'clock, A. M. Monday, April 1st. Pulse 100; gave a teaspoonful of 
salts. 5, A. M. Pulse 98 ; has been rather resfless since 3, A. M. 6, A. M. 
Pulse 96 ; no operation on tlie bowels ; gave another injection, which ope- 
rated soon ; stools liquid, and very fetid ; mouth more moist ; thirst stfll 
considerable. 9. A. M. Pulse 96; skin cooler; bowels continued open 
during the last hour. 10^, A. M. Pulse 97 and soft; drew oflf half a pint of 
highly coloured urine; skin soft and pleasant; inclined the patient towards 
the left side. 7, P. M. Pulse 100; the patient moans; thirst; abdomen 
tympanitic; complains of slight pain on pressure ; sickness of the stomach 
after drinking; palms and soles dry; administered an injection of flaxseed 
tea; drew off four ounces of urine highly coloured. 8^, P. M. Injection 
passed with a good deal of wind of a fetid smell. 10, P. M. Pulse 98, soft; 
has had a good sleep; gave an injection. 11, P. M. Pulse 96; skin moist; 



56 W. L. Atlee's Case of Extirpation of Ovarian Cyst. [July 

passed injection with considerable wind and some natural stool, and less 
fetid. 

Tuesday, April 2d, 2, A. M. Dr. Shellar gave her a teaspoonful of weak 
mint tea, which relieved her stomach of wind, and made her quite easy; 
pulse 96. 6, A.M. Pulse 97; passed urine herself with griping pain; bor- 
borygmi with frequent discharges of wind per anum. Slept a good deal 
during the night. 8, A. M. Pulse 95; skin moist; had two black stools 
since 6 o'clock, of a sour disagreeable smell. 9, A. M. Pulse 96; griping 
of the bowels ; palms and soles dry and hot; no pain on pressure over the 
stomach. 10^ A. M. Griping and frequent moaning since 9 o'clock ; dis- 
charged urine of a very disagreeable smell. 125, P. M. Administered half 
a teaspoonful of oil. I5, P. M. Pulse 96, compressible; a fluid of a brick 
dust colour, and of a very disagreeable smell, works up occasionally from 
the stomach; discharged per anum a good deal of wind of a very disagree- 
able smell. 3, P. M. Pulse 95; urinated an hour since; gave a half spoon- 
ful of oil, which was followed in half an hour by a stool of the natural colour, 
and in half an hour afterwards another of the same kind. 41, P. M. The 
patient visited by Dr. J. L. Atlee. The general symptoms favourable ; pulse 
100 ; skin natural, nose warm, cheeks cool, palms rather warmer than the 
rest of the body; wound dry; frequent eructations of wind, with ejections 
from the stomach of a yellowish offensive fluid, possessing a smell similar 
to that of the stools, but more faint and less fetid ; has had two small yel- 
lowish stools, evidently bile ; says the eructations are bitter, not sour ; no 
general tenderness of the abdomen, but from the left side upwards there is 
some tenderness, diminishing as we ascend ; there is considerable distension 
along the whole track of the colon. 8, P. M. Pulse 100, small and weak; 
skin as before ; has thrown ofl" the water occasionally which she takes for 
several hours past; distension continues. Gave a flaxseed injection with a 
tablespoonful of the aqueous solution of assafoetida. 9, P. M. Dr. Shellar 
has the patient in charge to-night. She has had a half an hour of sound 
sleep; pulse 100; skin of the natural temperature; still troubled with eruc- 
tations of the same nature as during the afternoon, though not so frequently ; 
some of the injection discharged with some flatus ; not much tenderness of 
the abdomen, still distended. Repeated the assafoetida injection, which 
brought away a great deal of wind, but no feculent discharge. Passed urine 
voluntarily, i3eing very highly coloured and having a strong smell. IO5, 
P. M. Symptoms the same, hands cool ; gave ol. ricini et spirits tereb. 
aa^ss. 11, P. M. Pulse 102 ; ejected some of the medicine. 

I5, A. M. Wednesday, April 3d. Pulse 102; hands warm; othersymp- 
toms the same; discharged a large quantity of wind; then fell asleep soundly 
for three quarters of an hour ; complains of a burning in the throat and sto- 
mach, caused by the medicine; eructations not so frequent. 2, A. M. Pulse 
102, compressible; symptoms the same, excepting that she feels easier and 
can sleep; gave an injection. 3, A. M. Pulse 104; tenderness of the epi- 
gastrium and general uneasiness ; discharges wind per rectum. 4|, A. M. 
Pulse 124 ; abstracted from the arm about three ounces of blood, after which 
the pulse sunk to 114; hands and face cool; eructations returned; dis- 
charged urine. 6, A. M. Pulse 120; hands getting warmer by the applica- 
tion of warm cloths ; sickness and eructations of the stomach continue. An 
express was sent off" at 4^, A. M. from Mr. S., distance 10 miles, by Dr. 
Shellar, to Lancaster, desiring our immediate attendance, and intimating the 
most unfavourable turn to the patient's symptoms. I arrived at 85, A. M., 



1844.] W. L. Atlee's Case of Extirpation of Ovarian Cyst. 57 

but found the patient rapidly sinking, the pulse being almost imperceptible, 
and too frequent to be counted ; the hands and wrists cold and clammy; and 
■very great distension along both sides and in the epigastrium, the abdomen 
less elevated alon^ the track of the wound. Fearino^ some intestinal obstruc- 
tion, perhaps incarceration of a portion of the intestine in the track of the 
wound, as in one of Mr. Walne's cases, I examined the wound carefully, 
withdrew all the needles, but could discover no cause existing there. Fearing 
that the ligature near the sigmoid flexure might have strangulated that part of 
the colon, I endeavoured to introduce a rectum tube, but could not succeed in 
passing it in more than four or five inches. In surveying the obstruction in 
the rectum with my finger, I struck agaiii against the same tumour which 
we had encountered in all our examinations before the operation, but thought 
it might be nothing more than a knuckle of intestine very much distended, 
and occupying the same location. I now administered injections of turpen- 
tine and gave brandy and water, but without avail, and the patient sank into 
the arms of death at three-quarters past 9, A. M. 

Jlutopsy one hour after death. — The abdomen externally was found sunk 
along the track of the wound, particularly about the umbilicus ; it was promi- 
nent along both sides, most so on the right, and was marked by very great 
fulness of the epigastrium ; a depression existed between the epigastrium and 
each side. 

The whole wound was united excepting a quarter of an inch at the umbili- 
cus, and half an inch where the ligatures came out. The adhesions could 
be easily overcome by separating the edges with the fingers. Opposite the 
umbilicus, where the point of non-adhesion was, there was a small collection 
of bloody matter outside of the omentum, and also a small deposit of coagu- 
lated blood at the same place. The muscular or internal lips of the wound 
were slightly separated, between which the omentum was moderately ele- 
vated, but had no appearance of strangulation. Very slight adhesions existed 
between the anterior walls of the abdomen and the great omentum, this latter 
being spread over the intestines very much as we had placed it at the time of 
the operation. It was somewhat injected with arterial blood, and slightly 
inflamed, and its veins were congested. In endeavouring to raise the omen- 
tum from the small intestines, it was found to be attached to them, particu- 
larly at its lower extremity, and it appeared to dip down into the left side of 
the pelvis. In detaching it a considerable gush of serum rose up out of the 
left side of the pelvis. By raising the omentum the convolutions of the small 
intestines were discovered to be inflated, and suffused with a bright vermi- 
lion tint, particularly those most adjacent to the pelvis, and they were agglu- 
tinated by a soft albuminous exudation. The small intestines also adhered 
to the peritoneum lining the parietes of ihe abdomen at those points where the 
omentum did not intervene. The ileum was the most intensely inflamed, 
particularly near the valve of Bauhin, and a thick coat of lymph was depo- 
sited between its folds, and so bound down its convolutions as effectually to 
strangulate the bowel; there was also considerable distension of it, but the 
greatest distension was in the jejunum and duodenum. The stomach was 
greatly distended, but not much injected. The caecum was moderately dis- 
tended, but the ascending, transverse, and upper part of the descending colon 
was empty and very much contracted. A small quantity of flatus was in the 
lower part of the descending colon, but the sigmoid flexure was very much 
contracted and inflamed ; the rectum being less so. The transverse colon 
particularly, was very firmly contracted and inflamed, having a bloody spot- 
ted appearance, and the omentum attached to it was very much injected, A 



58 W. L. Atlee's Case of Extirpation of Ovarian Cyst. [July- 

dense deposit of dull-white lymph was found about the intestines in the left 
lumbar region. On separating the folds of the intestines, a large quantity of 
sero-purulent fluid escaped, particularly from the iliac and pelvic fossae. In 
some of the interspaces there was actual pus, appearing like small abscesses. 

The pelvic viscera were glued together. The right ovary was seen in the 
same condition as at the time of the operation, excepting that it had formed 
loose attachments to the parts around. The womb was considered somewhat 
hypertrophied for a person at her age. 

We now determined to remove the womb, right ovary, rectum, sigmoid 
flexure, and the remains of the pedicle, with the ligatures attached. After 
relieving the viscera of all their surrounding attachments, and passing the 
hand deeply into the pelvis to raise them out, a globular cyst, about the size 
of an orange, was lifted up from the deepest part of the pelvis, and was 
found to be pendulous from the right ovary. The uterus was severed just 
below its cervix before its removal, and there issued from its cavity, at the 
points of section, a yellowish thick gelatinous fluid. . 

On examining the parts after their removal, the first ligature was found to 
be attached to the posterior wall of the broad ligament, including the round 
ligament, near the body of the uterus, and about a quarter of an inch beneath 
the fallopian tube. The second enveloped the fallopian tube and large ves- 
sels about two inches from the uterus. The third also enclosed the fallopian 
tube and vessels about half an inch further on. And the fourth included the 
sheet of membrane and vessels between the tumour and sigmoid flexure, 
about half an inch distance from the latter. The examination of the parts 
on the right side of the uterus was exceedingly interesting and satisfactory: 
the right ovary was healthy, there being no cystic degeneration within it or 
the fallopian tube, and having no immediate connection with the cyst which 
had occupied the pelvis on the right side. The cyst had its origin exclu- 
sively in the broad ligament, projecting from its posterior walls, had a 
pedicle about two inches broad, was suspended at a distance of one inch at 
least from the fallopian tube and ovary, the latter being entirely free, and its 
distance from the body of the uterus was about one inch and a quarter, it 
being supported on that part of its pedicle by the round ligament. The cyst 
must have occupied the recto-vaginal cul de sac of the peritoneum, and must 
have been driven down against the coccyx by the distended cysts of the left 
ovarium. lis very low position in the pelvis may be understood when it is 
mentioned that the anterior duplicature of the peritoneum was reflected off 
from the broad ligament to the pubic portion of the pelvis, about half an inch 
above the highest portion of the cyst, and that the same point of the latter 
was at least two and a half inches below the fundus of the uterus. The 
uterus was lined with a beautiful velvety scarlet membrane; the orificium 
internum was studded with diaphanous papillary vesicles, which, on being 
cut, eflfused a gelatinous kind of fluid; the dilated part of the cavity, corre- 
sponding with the cervix, was plainly marked by the ridges denominated 
arbor vitae uterinus. The uterus was about three inches long, two inches 
wide, and its walls about half an inch thick, being perfecfly healthy in struc- 
ture. The sigmoid flexure attached to the detached parts was contracted 
in size, and very much inflamed, particularly near the ligature around the 
pedicle. This very interesting specimen I have carefully preserved. 

Description of the extirpated tumour. The tumour, immediately after 
the operation, weighed ten and a quarter pounds; it lost three-quarters of a 
pound weight in twelve days, being suspended in diluted alcohol, after 
which the following observations were made. The greatest circumference 



1844.] W. L. Atlee's Case of Extirpation of Ovarian Cyst. 59 

of the tumour is two feet nine inches, the smallest two feet. Its shape is 
irregularly pyriform, with a cordiform indentation at its narrowest end. The 
marks of the trocar are plainly visible, and, when placed in a horizontal 
line, indicate very accurately the position of the tumour within the abdomen 
at the time of tapping. The cordiform indentation, with its bulging lips on 
each side, occupied the pelvis, and most probably received within it the 
fundus uteri. The larger end of the tumour occupied the epigastrium, and 
the septum between the cysts, two of which constituted the entire tumour, 
run obHquely down on the left of the linea alba, gradually approaching it in 
its descent. It was very evident, from comparing the old with the recent 
marks of the trocar, that the tumour had changed its position to a small 
extent after the first tapping, and that the upper portion was thrown over 
more to the left, and the lower to the right side. The pedicle had a most 
extensive attachment to the tumour. Starting at the inferior portion of the 
septum, by the insertion of the round ligament, it sweeps around the bulging 
part of the left side of the tumour, and returning again to the septum termi- 
nates in the fundus of the tumour, making an attachment of thirteen and a 
half inches in length, even in this state of the sacs, they being only half 
filled with fluid. This measurement includes several inches of the pedicle 
which were not touched by the knife. The length of the cut portion, 
measured on the tumour, is nine and a half inches, and the part of the fal- 
lopian tube, attached to the tumour, is five and a half inches in length, which, 
added to the uterine portion, gives the great length of eight or nine inches. 
The fallopian tube terminates in a dense mass in the fundus of the tumour, 
which appears to be the ovary disintegrated and difiused through the struc- 
ture of the cyst in that part, and the fimbriated extremity is stretched over a 
considerable space on the posterior wall of the fundus. This is much the 
most dense part of the cysts, excepting the septum, which forms dense 
ridges upon the surface of the tumour, and plainly points out its own loca- 
tion, The right sac is the largest. The walls of the cysts are a very dense 
white structure, interspersed with a few transparent spots. 

From the position of the sigmoid flexure, and its connection with the 
pedicle, i have no doubt that as the cysts became developed, they elevated 
the posterior fold of the broad ligament as it is reflected ofi" to the sigmoid 
flexure, and stretching it as they enlarged, thus elevated the intestine and 
involved it in the pedicle. Indeed, from the circumstance of the round 
ligament being inserted in the lower part of the septum, and the fimbriated 
extremity of the fallopian tube being spread upon its upper part, with the 
whole tube swinging entirely free of the tumour, there is every reason to 
believe that it originated, like the other cyst, in the posterior walls of the 
broad ligament, and in this way more readily involved this intestine. 

Remarks. — I have given this unfortunate case in full detail, in a con- 
scious spirit of truth and candour, because it is an unsuccessful one. It 
is not so much to avoid the censure of "keeping studiously and carefully 
from the public eye the unsuccessful cases of the operation," (Mr. Law- 
rence,) which is a species of dishonesty and empiricism deserving unqualified 
condemnation, as to do an act o^ professional duty peremptorily required 
by the unsettled position of this operation in the minds of the most eminent 
surgeons, that induces me to its publication. I have carefully avoided 
giving any colour to the case, save what its symptoms have expressed, and 



60 W, L. Atlee's Case of Extirpation of Ovarian Cyst. [July 

I am perfectly willing to furnish it as one of the numerical arguments 
against ovariotomy. Still, candidly admitting the case to be fairly one of 
unsuccess, notwithstanding the mitigating circumstances of age, constitu- 
tion, and insidious inflammation, I as coiifidently as ever consider the ope- 
ration justifiable in appropriate cases of a disease otherwise desperate and 
incurable, and where it ^^ secures the only remaining chance of life.'''' — 
(Blundel, Medical Examiner.) 

In reviewing the history and symptoms of this case, it must be admitted 
that every thing led to the opinion of the right ovary alone being diseased : 
pain in the right side, neuralgia of the right thigh, tumour in the right side 
of the pelvis crowding the uterus to the left, pressure elevating this tumour 
into the right groin, evident attachments of the tumour to the right side of 
the uterus, nothing abnormal occupying the left side of uterus — each, singly, 
drew attention to the right ovary, and, collectively, almost indubitably indi- 
cated the location of the disease. On the other hand, the swelling of the 
left leg, and ilieflat sound over the left lumbar region after tapping, were the 
only symptoms which could draw attention to the left ovary. The first 
symptom could be explained by the peculiar anatomical arrangement of the 
iliac vessels ; for, according to my observation, it is a fact, only explicable, in 
my opinion, by the anatomy of certain parts, that the left leg is more liable 
to oedema, varicose veins, &c., resulting from pressure within the abdomen, 
as in pregnancy, &c., than the right leg. The right common iliac artery, 
traversing the left common iliac vein, just below its termination in the 
ascending cava, and where it lies upon the resisting prominence of the fifth 
lumbar vertebra, must necessarily obstruct the circulation in the inelastic 
vein whenever subjected to the insistent pressure of a tumour, and thus 
impeding the whole venous circulation of the left leg, while the supply of 
blood would be continued through the elastic resisting artery, lead to an 
oedematous or a varicose state of this limb sooner than the other. The 
second symptom, or dulness of sound, could be explained by supposing that 
the flaccid cyst might be retained in the left lumbar region by omental 
adhesions, a circumstance not at all unusual in ovarian tumour. With this 
explanation, the conclusion, that the disease was in the light ovary was 
irresistible. 

The operation, therefore, was commenced with every confidence of find- 
ing the pedicle of the tumour attached to the right side of the uterus, and 
our astonishment was great in discovering the tumour, at this point, entirely 
free, and its pedicle, which was the only attachment, arising out of the oppo- 
site side. Although this circumstance could not affect the course or the 
result of the operation, it yet so conflicted with the diagnosis as to convince 
us of the truth of the antecedent of the enthymeme, assumed by those un- 
favourable to gastrotomy, that the " very impossibility of knowing beforehand 
the exact condition of the organs which it is proposed to extirpate forms one 
of the strongest arguments against the operation," {The British and Foreign 



1844.] W. L. Atlee's Case of Extirpation of Ovarian Cyst, 61 

Medical Review,) without establishing the consequent deduced from it. De- 
siring, however, to explain the contradiction, we considered that the lower 
end of the cysts, which had been wedged into the pelvis, had been tilted 
over upon the right side of the uterus, and dipping deeply down had simu- 
lated the tumour, which we had previously felt in that location, and that that 
portion of the cysts contained an indurated portion of the ovary, which had 
continued in situ after the fluid had been removed. In order, however, fully 
to satisfy ourselves that the right ovary was not diseased, I took it up in my 
fingers, with the fallopian tube, and a considerable portion of broad liga- 
ment, examined it carefully, and exhibited it to the gentlemen around. We 
all considered it healthy, and so it was pronounced. Had our patient re- 
covered after the operation, the true state of things could never have been 
known, and the case would have been reported in accordance with the above 
state of facts. The consequence would have been, that her disease ivould have 
returned, and its return would have been attributed to a subsequent develop- 
ment of diseased action in the right ovary, which had been perfectly healthy 
at the time of the operation. Here then would have been another blow to 
the advocates of gastrotomy, so that living or dead the case would have 
been used against them. In order, therefore, to make the operation doubly 
sure, the extirpation of both ovaria, the healthy as well as diseased, would 
have to be resorted to — a course which I had previously contemplated in 
patients who had passed the climacteric period of life. The patient, how- 
ever, died, and was subjected to a post-mortem examination. This revealed a 
state of things which was equally as astonishing, and which, although appa- 
rently contradicting the unanimous opinion expressed at the time of the 
operation, essentially confirmed the diagnosis: there was a tumour attached 
to the right side of the uterus. It was this very tumour that had been felt 
previously to the operation, and also after it while employing the rectum 
tube when the patient was moribund. It was only discoverable per vaginam 
vel per rectum, and was entirely out of view when the abdomen was opened 
and the pelvis examined through its superior strait, both during the opera- 
tion and the autopsy. Now it is such cases as this that often leads to the 
most important precautions in practice, and in a similar case 1 would not 
close the wound until I had fully satisfied myself by a vaginal examination. 
The publication of this case, therefore, may produce this, if no other good 
in ovariotomy: establish the rule never to finish the operation without such 
an examination. It must be very evident that the mere survey of the ovary 
is by no means sujfficient, and that the cases of return of this disease on 
record may be accounted for in this way. An examination of this kind, in 
addition, is thorough, is the only way to avoid difficulty, and to clear up all 
doubt. 

In reference to the cause of death, peritonitis, there were none of the 
ordinary indications of this disease, nor any symptoms requiring particular 
treatment, until the evening of the fifth day. Indeed, it was a matter of 
No. XV.— July, 1844. 6 



62 W. L. Atlee's Case of Extirpation of Ovarian Cyst. \J^^y 

general surprise, how little disturbance so great a wound had produced/and 
that not a single unfavourable symptom arose during or for several days after 
the operation. I have no doubt, from the post-mortem appearances, that 
inflammation supervened before the fifth day, and that this was one of those 
anomalous cases of peritonitis, which steals on insidiously, where the bowels 
act without impediment, where vomiting and unusual gastric irritation do not 
exist, where the pulse seldom exceeds 100, and where the state of the sliin 
continues natural, and even where tenderness of the abdomen is not remark- 
able. There had been no rigors; no acute pain, nor great distress from pressure, 
nor feeling of incumbrance from the bed-clothes; no obstinate constipation; 
no nausea and vomiting until the last evening; no dry and hot skin; no 
rapid, small, and hard pulse ; no white furred tongue and dry lips ; nothing 
indicating inflammation of the peritoneum. The tenderness of the abdomen 
and flatulency, the only symptoms, were not at all remarkable, and not greater 
than would be likely to arise from the healthy inflammation of such a wound. 
By this apparently very favourable condition of the patient we were lulled 
into inaction, and at the very time we were congratulating her and ourselves 
upon her having passed the time of greatest danger so well, the disease, no 
doubt, was quietly making the most dreadful havoc. Had the usual evi- 
dences of peritonitis existed, we were prepared and watching to meet them 
in their onset, and thus met they most probably would have succumbed to 
our measures. The question may here be asked,— had age, or the shock 
from the operation, or both together, any agency in so diminishing the sus- 
ceptibility of the system as to render it incapable of noticing this state of 
things ? The nervous shock was certainly not great, and gradual and appa- 
rently wholesome reaction supervened in good time. Her age, therefore, 
conjoined with a feeble and debilitated constitution, may perhaps account for 
the want of the necessary elasticity of fibre. 

The extreme sensitiveness of the peritoneum, and the congested state of 
the mesenteric veins at the time of the operation, may have had considerable 
influence in causing peritonitis. The section of the peritoneum, and the fric- 
tion of the hand against it, produced infinitely greater manifestations of suffer- 
ing than any other part of the operation. This did not exist in my brother's 
case, and it is not stated as having occurred in any other that I have seen 
reported. It was, however, remarkable in this instance, and excited the 
attention of all present.* 

* Another instance of extensive exposure of the peritoneuna, occurred in my practice 
in June, 1830. I was called to see Master D. L., a lad about ten years old, who had been 
attacked by a furious cow, which had just calved. She threw him down into the corner 
of a worm-fence, and gored him most dreadfully. The most serious wound was in the 
walls of the abdomen : the point of the horn entered at the superior spinous process of 
the ilium on one side, crossed the abdomen transversely, and came out at the same point 
on the opposite side, ripping- open the whole intermediate space. The wound gaped at 
least three inches, owing to the retraction of the divided muscular fibres. Fortunately 
the peritoneum was not wounded. The point of the horn appeared to have insinuated 



1844.] W. L. Atlee's Case of Extirpation of Ovarian Cyst. 63 

Another circumstance, which I believe is unique in this case, is the impli- 
cation of the intestine within the pedicle of the tumour. In Professor Lizar's 
third case, and in Dr. Chrysmar's first case, both of which proved fatal, the 
former in 53, the latter in 36 hours, there were adhesions of the colon to the 
tumour, {The British and Foreign Medical Review,) but in neither of these 
cases was it involved within the pedicle. In this case it was, and so closely 
approximated the tumour, that only one inch of pedicle existed between the 
two, upon which to apply the ligature. At this point on the intestine, and 
in the adjacent small intestines, the marks of inflammation were intense. 
Did the inflammation originate here and radiate to the parts contiguous ? 
Pathologists inform us that the effect of contact in propagating serous inflam- 
mation, is more obvious than that of continuity. 

This case would seem to show that tapping, either as an aid to diagnosis, 
or prospective to an operation, is not objectionable as inducing adhesions. 
Dr. Frederick Bird is of the same opinion. (Braithwaite^s Retrospect.) Dr. 
Charles Clay, however, is "averse to puncturing, because at the places punc- 
tured adhesions are effected, and by the alternate distension and collapse of the 
sac, fresh adhesions are also formed in other parts." (Ibid.) In my case 
not the least adhesions existed, notwithstanding suppurative inflammation 
supervened in the abdominal walls after one of the tappings, a circumstance 
highly calculated to produce them. 

It must have been observed in the report of this case, that before the opera- 
tion the uterus was considered atrophied, and that during the operation, and 
also at the autopsy, it was considered hypertrophied for the age of the patient. 
Its exact measurement is given, and it corresponds with the size of a healthy 
womb in the child-bearing period of life. Could both conditions have existed 
at the several periods of observation ? The query is of no moment excepting 
as connected with the diagnosis, and may, I think, reasonably be answered 
in the affirmative. It possibly was in a state of atrophy, and may have 
become hypertrophied by subsequently increased action within itself, as was 

itself between the peritoneum lining- the parietes and the fascia transversalis, and the con- 
vex body of the horn skated upon the peritoneum without tearing it ; every thing anterior 
lo it was ripped asunder, and a clean, even, incised-like wound remained.' The convolu- 
tions of the bowels were plainly visible through the semi-transparent peritoneum, which 
was the only thing that prevented their escape, being- placed like a glass in front of them. 
in riding- hastily to the place I lost my case of instruments, and had nothing' but a roll of 
adhesive plaster with which to dress this extensive wound, I, however, brought the lips 
of the wound carefully together, and secured them with very long straps of plaster, with- 
out the aid of a single ligature. Then placing the patient on his back with the shoulders 
and hips elevated, I gave a dose of laudanum to keep the bowels quiet, placed him on 
absolute diet, and had him watched night and day to prevent motion of the body. Con- 
tinuing rigidly this let-alone treatment for several days, the whole wound healed up by 
the first intention. The bowels were acted on for the first time by oil on the fifth day, 
and the patient recovered without a bad symptom, In this case also, no tenderness of 
the peritoneum was evinced by handling. 



64 W. L. Atlee's Case of Extirpation of Ovarian Cyst. [July 

indicated by an augmentation of tenderness at and after the second tapping. 
The relative position of the tumour and the womb, the top of the former, 
after the removal of the parts, being two and a half inches below the fundus 
of the latter, may perhaps have misled us in regard to its atrophied state, as 
the cervix uteri corresponded with the body of the tumour, and may have 
been mistaken for the womb itself. 

Aiding in the diagnosis of our case, there was one very prominent symp- 
tom, which I do not remember of having seen noticed by writers in any other, 
but which I think would generally obtain in encysted dropsy: the pulsations 
of the abdominal tumour, and the impulse of the aorta. In great abdominal 
enlargement, under the very circumstances when the difficulty of distinguish- 
ing between peritoneal and ovarian dropsies arises, I think that this would be 
^pathognomonic feature of great value. The impulse of the aorta upon the 
resisting walls of a distended cyst, would communicate fluctuation in all 
directions, in the same way that the impulsion of the fingers upon the walls 
of the abdomen produces a corresponding motion in ascites, while at the 
same time the aortic impulse in the latter, for apparent reasons, would be 
exceedingly feeble or not at all recognizable. In Miss R.'s case, the only 
thing in dispute between my brother and myself remaining unsettled until 
the operation, was in relation to the character of the dropsy. It was ovarian 
tumour and peritoneal dropsy, a case entirely unique in the medical records 
accessible at the time. Taking all the diagnostic indications collectively, it 
was admitted on both sides, that its character was obscure. In that case the 
abdominal pulsation was absent. 

It is worthy of being observed that the fluid drawn from these cysts, was 
different from that which we find in the majority of cases, and as this is 
esteemed one of the most valuable diagnostic signs, I desire to refer to it here. 
Dr. Alexander Kilgour, who furnishes some valuable hints on the diagnosis 
of ovarian disease, observes that "in most cases of encysted ovarian dropsy 
the fluid is thicker than serum, flowing through the canula of the consistence 
of train oil, of a greenish or dark colour, and of a saponaceous feel. Some- 
times it is grumous, like drained honey, or like jelly; or it assumes these 
characters as the sac becomes emptied. Nitric acid added to it produces 
a thick coagulum, and so also does boiling. When these characters are pre- 
sent, there can be no doubt as to the nature of the dropsy." [Jim. Journ. Med, 
Sci., Oct. 1843, p. 489.) This is true, and such a fluid unfailingly distin- 
guishes ovarian dropsy from every thing else. But there are cases of ovarian 
dropsy, not alone "unilocular," where the fluid is not so easily distinguished 
from that of ascites, and where, if we possessed no collateral aid in diagnosis, 
it could not serve us in deciding upon the nature of the disease. Such was 
this case. The physical characters of the fluid corresponded in density, 
colour, and transparency, with ascitic ; and its chemical character, as tested 
by heat and nitric acid, exhibited similar evidence to that of ascites, tested in 



1844.] W. L. Atlee's Case of Extirpation of Ovarian Cyst. 65 

two instances since. The only difference discoverable between the two fluids 
was in the amount of albumen, the ovarian containing more, and therefore 
being more densely coagulable than the peritoneal. This property, therefore, 
not being exclusive, will not always be available as a characteristic sign, and 
it being only relative in degree, must prove uncertain in inexperienced hands, 
particularly when not associated with distinguishing physical characters. 

I would also call attention to the condition of the cysts after tapping. 
They were collapsed into folds and ridges, which could be felt plainly 
within the cavity, and entirely distinct from the walls of the abdomen. 
How far the position of the cysts after paracentesis will diagnosticate adhe- 
sions may be presumed from this case, in which none existed. The effect 
of attachments between the cyst and walls of the abdomen would no doubt 
be a proportionate augmentation in the thickness of these walls, with a feel- 
ing of double folds in pinching them up between the fingers. Where the 
sac has receded from the walls of the abdomen, and forms rugae within, 
there is strong presumption, if not absolute certainty, of the absence of 
adhesions, at least to the abdominal parietes. This state of the cysts also 
affords very strong pathognomonic evidence, for in ascites nothing of this 
kind would be presented. 

The fact of the tumour having been composed of only two large cysts, 
free from adhesions, and independent of any great amount of solid deposit 
within its walls, would appear to render it a case peculiarly adapted to Jeaf- 
freson's operation, but the great extent of the pedicle, its investment of the 
colon, and the proximity of the latter to the cysts, would plainly have ren- 
dered it equally, if not more immediately hazardous. Jeaffreson's operation, 
particularly as modified by Dr. Frederick Bird, is certainly worthy of imita- 
tion, but in many cases must necessarily yield to the large peritoneal section. 

In peritoneal sections for the extirpation of ovaria I have thought that 
there might be less liability to inflammation than in wounds where such or 
similar disease does not exist. The constant friction of the tumour, and the 
distension of the peritoneum, may tend towards obtunding its sensibility, and 
rendering it less liable to react upon the application of irritants. In the 
above case, however, there evidently was a morbid state of irritability, a 
state of hyperemia existing in this membrane at the time of the operation, 
unusual in other cases, rendering it more liable to inflammatory action. With 
this view of the case, I doubt whether we "should be justified in making 
extensive incisions into the abdominal cavity for other objects than the one 
here related," (Dr. Charles Clay, Braithwaite'' s Retrospect,) basing the pro- 
priety of such operations merely upon the success of ovarian cases. 

The British Medical Journals, in reviewing the cases of Dr. Charles Clay, 
and others, speak decidedly against the operation of gastrotomy. As the 
subject has become one of vital importance, and as this has been styled an 
American operation, I propose concluding my paper by noticing one or two 
points in the English Journals. 

6* 



66 W. L. Alice's Case of Extirpation of Ovarian Cyst. [July 

One writer, in the general scope of his paper, takes a candid and fair view 
of Clay's and other operations, and very properly corrects some of the sta- 
tistical errors which Dr. Clay permitted himself to embrace in his report. 
However much it must be regretted that any member of the profession, as 
distinguished as Dr. Clay, should attempt to establish an operation by unfair 
means, or by disparaging and misrepresenting the manner of operating and 
success of other surgeons, still it must be equally regretted that his reviewers 
should place the merits of the major operation in juxtaposition with the errors 
of Dr. Clay, and thus condemn together what are essentially disconnected, 
and decry the value of the one with the same breath used in combating the 
other. 

One of the principal objections brought forward by the British writers is 
the difficulty of forming a diagnosis in cases of ovarian diseases. " The 
impossibility of ascertaining either the existence of any disease of the ovaries, 
the real character of such disease, or the adhesions or connections which it 
may have originally held, or have formed during the progress of its growth, 
has been freely granted by every experienced physician and surgeon who has 
directed his attention to the subject, and is also made abundantly manifest by 
the cases of extirpation which have been recently recorded," {^The London 
and Edinburgh Monthly Journal of Medical Sciences.) The ''very im- 
possibility of knowing beforehand the exact condition of the organs which it 
is proposed to extirpate, forms, in our opinion, one of the strongest argu- 
ments against the operation; and will always do so until we are furnished 
with some unerring means of distinguishing between simple ovarian tumours 
and cases in which ovarian cyst^ are associated with other diseases of those 
organs." {The British and Foreign Medical Review.) That there is a 
difficulty in diagnosis in some cases must be admitted, and in such the whole 
force of the argument ought peremptorily to operate. Some of the fatal 
eases referred to by the writers, I think would be obnoxious to this charge, 
and ought to exhibit more the temerity of the surgeon in undertaking ovari- 
otomy where the diagnosis was obscure, or the malignancy of the tumour, 
and other circumstances, contraindicated it, than to undervalue a well-judged 
and well-timed operation in cases where nothing objectionable obtains. 
While, however, admitting the position in some cases, we do consider it 
untenable in others, and cannot admit that there is an impossibility of know- 
ing the condition of things beforehand in all cases. The possibility of correct 
diagnosis, at least as to the existence of ovarian disease, and in reference to 
the propriety of an operation, I consider has been sufficiently proved by the 
many successful, and even unsuccessful cases of peritoneal section, and also 
by post-mortem observations where no such operation had been performed. 
And although errors may have occurred in certain cases, nothing less has 
happened in other kinds of surgery, where operations are acknowledged to 
be legitimate and proper. If, then, cases do occur, where doubt does not 
exist, ought the operation to be performed? The several successful cases, 



1844.] W. L. Atlee's Case of Extirpation of Ovarian Cyst, 67 

both of the minor and major operation, and the character of the disease to 
be remedied, speak sufficiently in the affirmative, and the writers themselves, 
in such cases, would not raise an objection, if a fair inference may be drawn 
from the above quotations. 

Another objection is the danger of hemorrhage. "The extent to which 
the incisions must be carried, and the adhesions which must be destroyed in 
many cases before the tumours can be removed, would lead us, a priori, to 
dread the consequences of loss of blood." {^The London and Edinburgh 
Monthly Journal,) It is rather surprising that this should have been offered 
as a serious objection against the operation, when we consider how rare 
hemorrhage has been in these cases, and how perfectly easy it is to control 
it by the careful application of ligatures. Is there one case on record where 
the cause of death could be legitimately traced to hemorrhage? Even in 
Mr. M'Dowell's third case, and in Mr, Lizar's second case, where hemor- 
rhage was profuse, death did not occur, and in Mr. Clay's fifth case, where 
death did occur, the hemorrhage, apart from other violence, was not so great 
as solely to account for the result. And whence is the great fear of hemor- 
rhage a priori? Large and important vessels seldom exist in the pedicle of 
ovarian cysts and tumours, and the attachments, which the latter may have 
formed with the surrounding parts, when organized, are supplied with the 
smaller class of vessels, while the extensive incisions through the skin 
involve no arteries worthy of notice. 

After giving details of several successful cases, it is observed : "All must, 
we think, agree with us in the opinion that the mere announcement that these 
thirteen persons recovered from the operation, would by no means suffice to 
enable us to estimate it aright. The sufferings endured during its perform- 
ance, the pains of a protracted convalescence, and the imminent danger in 
which life was placed in some instances, ought all to be taken into account. 
The sufferings and the danger too, in these cases, were neither few nor 
small." [The British and Foreign Medical Review.) The fact, I fear, 
has been overlooked that in other capital operations, legitimated by time and 
results, all the above circumstances occur, and that suffering, pain, and dan- 
ger, are necessary accompaniments. To balance this, look at the ovarian 
patient condemned, by the opponents to extirpation, to uninterrupted misery, 
to interminable sufferings, to all the agony and inconvenience of obstructed 
circulation, respiration, defecation and the functions of all the pelvic, abdomi- 
nal and thoracic viscera ; condemned to certain death by a protracted, incura- 
ble, burlhensome disease, draining her system of its usual pabulum, depriv- 
ing her of exercise and the pure air and light of heaven, and oppressing her 
with a loathsome enormous mass too great for her enfeebled, emaciated frame 
to carry. Thus metamorphosed, in the depth of her agony and affliction, 
she appeals to us for assistance, and though life may be the forfeiture, she 
stakes it willingly. What is to be done ? Take every thing into the esti- 



68 W. L. Atlee's Case of Extirpation of Ovarian Cyst, [July 

mate, and is not the operation not only justifiable, but sometimes criminally 
omitted ? 

It is also observed, that " there are objections, however, to the operations, 
far more conclusive than any which can be deduced from the inadequate 
nature of the testimony in its favour. Not only did six of the persons, 
whose ovaries were extirpated, die from the effects of the operation, but in 
eight instances, after the abdominal cavity had been laid open, the removal of 
thetumour was found impracticable, and the lives of three of these patients were 
sacrificed to the fruitless and ill-judged interference of the surgeon." [Ibid.) 
What capital operation, I would ask, is exempt from such a charge ? The 
victims of the knife have been numberless in almost every branch of opera- 
tive surgery: bladders have been cut for stone without finding any, legs have 
been amputated that ought to have been saved, hatfuls of eyes have been 
destroyed without restoring vision, aneurisms have been opened believing 
them to be abscesses, and a variety of other malpractice must occur to the 
mind of every surgeon. Does it follow from this that the operations of litho- 
tomy, amputation, cataract, and the lancing of abscesses ought to be con- 
demned? Is fruitless, ill-judged, or ill-directed surgery in a few instances, 
to be adduced in condemnation of any operation ? I apprehend not. Why 
then not place gastrotomy upon the same footing ? As a new operation, 
undergoing a course of probation, it is perhaps equally as successful at this 
age of its history, as some other operations, now established, were in their 
early infancy, and which, even now, occasionally illustrate the improper and 
fruitless interference of the surgeon. Upon this principle, operative surgery 
would become obsolete. 

Certain writers also throw out some very improper insinuations upon the 
motives of the younger members of the profession, who undertake what 
older surgeons " are reluctant to attempt." After representing this operation 
as exceedingly hazardous and fatal, and then accusing the young surgeon of 
endeavouring to advance his reputation by "exciting the astonishment of the 
vulgar," they must have forgotten the self-contradiction of their position, and 
the danger of young surgeons seeking professional eclat where censure only 
was to be encountered. And why thus assail the junior members of the pro- 
fession ? Where is the time-honoured surgeon, bending under the weight of 
years, and enjoying the full fruition of a successful career, that has not laid 
the foundation of his fame before time has begun to mark his temples with 
the frosts of age ? Whence have sprung the great improvements of our art ? 
Have they not mainly originated with men in the prime and vigour of life, 
before age began to enervate the mind, or routine to fix the habit? Then let 
it not be said that because the "aged and the timorous are reluctant to 
attempt" an operation, that the younger man, emboldened by assiduous 
investigation and new discoveries, should be censured for the innovation. 
The oath, " Nullius unquam hominis vitam ancipiti tentaturum experiniento," 



1844.] Wells' Surgical Cases and JRemarks. 69 

fortunately for gastrotomy, does not include the whole of medical morality; 
the principle will be more complete by adding, in English, and the life of no 
one should ever be sacrificed to a necessarily fatal disease when art can pre 
vent it. On this point the beautiful language of Hufeland is quoted : " Thine 
is a high and holy office, see that thou exercise it purely, not for thine own 
advancement, not for thine own honour, but for the glory of God, and the 
good of thy neighbour. Hereafter thou wilt have to give an account of it." 
There are sins of omission as well as of commission. The good of our 
neighbour, and our professional duty, always obligate us to risk our reputa- 
tion in contributing to the one, and in properly exercising the other; and if, 
when relief can be afforded in a horrible and fatal disease, we are unwilling 
to hazard our fame, or take responsibility in consequence of danger, then 
indeed we prostitute a high and holy office, fail to exercise it purely, and 
will have to give an account of it hereafter. The same German author elo- 
quently observes : " Der wahre Arzt soil kein anderes Interesse haben, als 
Gesundheit und Leben seines Kranken. .Tedes andere fuehrt ihm vom 
wahren Wege ab, und kann fuer den Kranken die nachtheiligsten Folgen 
haben. Er braucht nur in irgend einen Collisionsfall zu gerathen, wobey 
seine Reputation oder sein Beutel in Gefahr kommt, wenn er etwas zur 
Erhaltung des Kranken wagt, und er wird zuverlaessig lieber den Kranken 
sterben lassen, als seine Reputation verlieren."* [Makrobiotik, von Dr. 
Hi f eland.) 



Art. IV. — Surgical Cases and Remarks. By Thomas Wells, M. D., 
Columbia, S. C. (With two wood-cuts.) 

Case I. — Chronic Empyema — Paracentesis — Cavity Injected — Cure. 
Dr. Wm. M'Queen, a highly respectable member of the medical profession 
of Cheraw, S. C, aged about 33, five feet ten inches in height, stoutly built, 
active constitution, and of nervoso-lymphatic temperament, placed himself 
under my care early in June, 1836, for emphysema of the left side, of long 
standing. 

He gave me the following history of his case. He says, "I had a violent 
attack of pleurisy about the 20th of May, 1835, the intensity of which 
yielded in a few days to active treatment, but leaving me with constant pain 
in the left side, accompanied by considerable fever and a very frequent pulse, 

* The honest physician should have no other interest than the health and life of his 
patient. Every other leads him from the true path, and may result in the most injurious 
consequences to the sick. Should a case of difficulty arise, in which, by hazarding- any 
thing for his patient's preservation, he might endanger either his character or his purse? 
he would unfailingly rather let him die than sacrifice his own reputation. 



70 Wells' Surgical Cases and Remarks, [July 

ranging from 110 to 140 beats in a minute; there was also very great diffi- 
culty of breathing, and an inability to rest for a moment except on the 
affected side. For these symptoms I remained under treatment four or five 
weeks, when the pain and fever subsided; my appetite returned, and I re- 
gained slowly some strength and flesh, but the difficulty of breathing con- 
tinued, and I was a good deal harassed with palpitation of the heart. It 
was not, however, until some time in August, between two and three months 
after the first attack, that I discovered a fluctuation in the left cavity of the 
chest." "At that time there must have been a large quantity of matter col- 
lected ; for, upon examination, the left side of the chest was found to be con- 
siderably enlarged, and there was an evident displacement of the heart." 
"My disease was supposed to be dropsy of the chest, and was treated 
accordingly; but gradually growing worse, and believing I had mistaken the 
nature of my case, I at length determined to consult you."* 

On his arrival in Columbia his condition was most painful; he had more 
or less fever every night of a hectic character; suffered greaUy from dyspnoea 
and palpitation of the heart, which were aggravated by an attempt to ascend 
a flight of stairs; the pulse was small and very rapid; the face bloated and 
the eye dull; the countenance expressive of great anxiety and distress; his 
appetite and digestion bad, bowels irregular; his sleep much disturbed and 
unrefreshing. 

On examination of the thorax the heart was felt beating in the right side, 
at a point corresponding nearly with its normal situation in the left. There 
was no respiratory murmur to be heard on the left of the mediastinum. The 
left side of the thorax was found by admeasurement something more than 
one-third larger than the right; the intercostal spaces increased in width, and 
pressed outwards beyond the level of the ribs ; the left shoulder considerably 
elevated; the liver, stomach, &c., pressed downwards, giving great promi- 
nence to the upper part of the abdomen. 

Dr. M'Queen was fully advised of his situation, and was satisfied that his 
only chance of recovery, or of prolonging his life, depended on the removal 
of the fluid from his chest by an operation; this being agreed upon, he took 
some doses of alterative aperient medicine, confined himself to a bland diet, 
and observed a state of quietude in his chamt)er, until the morning of the 
7th of June, when the operation was performed in the following manner. A 
broad bandage was passed around the chest, ready to afford a regular degree of 
pressure as the fluid should be discharged; he lay upon the edge of the bed, 
upon his back, a little inclining to the right side, with his head and shoulders 
somewhat elevated; an incision was made, about an inch in length, with a 
double-edged scalpel, through the integuments upon the upper edge of the 
seventh rib, and a little nearer to its spinal than its sternal extremity; the 
scalpel was then thrust into the cavity of the chest in the middle of this 
incision; a gum elastic bougie, of good size, with a large eye, was intro- 
duced through the puncture, and between two and three quarts of thin, 
inodorous pus drawn off; at first he expressed himself much relieved from 
the discharge, his breathing became freer, and he felt less oppression; but 
after the above-mentioned quantity of matter had been discharged, he began 
to complain of faintness, and the instrument was withdrawn. A piece of 
adhesive plaster was placed over the incision. The bandage was made 
moderately tight about the chest and left on; all unpleasant effects from this 

* This history was given me in a letter by Dr. M'Queen some time after his return 
home. 



1844.] Wells' Surgical Cases and Remarks, 71 

operatiorf soon passed off. In the afternoon of the same day the same in- 
strument was again introduced, the point turned backward towards the pos- 
terior walls of the thorax; and intending now to draw off the whole of the 
fluid, if this could be borne, care was taken to exclude the air from the 
thoracic cavity; the skin was pressed about the instrument by the fingers of 
an assistant; the end was held between the thumb and middle finger, with 
the forefinger ready to close the orifice as soon as a full stream ceased to 
flow. He however began to complain of increasing embarrassment in his 
breathing, after about two quarts had been discharged, before any change 
took place in the stream of matter, and the process was again suspended. 
For a short time after this operation he perspired freely; complained of 
great oppression and difliculty in making a satisfactory inspiration, and of 
faintness. These symptoms were, however, soon removed by tightening 
the bandage around the chest; a few spoonsful of wine and some light 
nourishment, and at evening an anodyne draught. 

June 8th. He has had a decidedly better night than for a long time; feels 
this morning in better spirits. In the middle of the day the tube was again 
introduced, with the same precautions, and the fluid allowed to flow until 
the stream was interrupted. About two quarts were drawn off at this time, 
making in all between six and eight quarts, and there must still have been a 
considerable quantity remaining in the thoracic cavity, which the contraction 
of that cavity was not sufficient to force through the tube. He experienced 
comparatively little inconvenience from this operation ; the day was passed 
with but slight constitutional disturbance. His bowels were opened, and an 
anodyne ordered at night. The bandage was kept firmly applied about the 
chest. 

9th. Had some febrile excitement last night; did not sleep so well as the 
night before, and complains this morning of a sense of fulness in the left 
side; a full quart of matter was drawn off to-day, which relieved him from 
the sense of oppression complained of in the morning. Ordered blue mass, 
and ext. cicuta aa gr. v., and an aperient dose for the morning. 

loth, P. M. Bowels have been moderately moved, and he feels much 
relieved, but complains again of the sense of fulness, no doubt, as he thinks, 
from the accumulation of fluid in the pleural sac. On attempting to intro- 
duce the tube to-day, it was found that the parts had adhered to such an 
extent as to render it impracticable; had to make a new incision; about the 
same quantity of matter was drawn off as yesterday. Just as the fluid 
ceased to flow to-day he made a sudden and full inspiration, and a quantity 
of air passed into the cavity ; a small quantity may have passed in yesterday. 
It now appearing that this operation would have to be repeated daily for some 
time, a tent was introduced into the orifice to keep it open, and to avoid all 
future cutting, a thing much dreaded by the patient. 

11/A. Has considerable febrile excitement this morning, and complains of 
soreness about the chest; pulse accelerated, and breathing rather more em- 
barrassed. Drew off about a quart of intolerably fetid matter, of a darker 
colour than before. Fractional doses of tart, antim. and tine, opii ; fomen- 
tations to the chest. 

I2th. Less fever; same quantity and quality of discharge; same treatment. 

I3th. Febrile excitement last night moderate; discharge not diminished 
in quantity; fetor the same; his strength has sensibly decreased within the 
last three days ; complains of languor and general malaise. It was now 
evident that something must be done to lessen the quantity of this morbid 
secretion, and to correct its quality, or our patient would, at no distant 



72 Wells' Surgical Cases and Remarks, [J"ly 

period, sink from exhaustion and irritation. After the matter wss discharged, 
about a quarter of a pint of a weak solution of chloride of soda was injected 
through the same tube, and suffered to remain about ten minutas, and then 
to pass out again, without any effort to withdraw the whole. 

lUh. He not only did not experience any inconvenience from the solution 
injected into the pleural sac, but is essentially relieved by it; the irritation 
and fever much less this morning; about the same quantity of fluid with- 
drawn, but less fetid; a larger quantity of the solution of the chloride of 
soda was injected, and after some minutes suffered to flow back again, as on 
yesterday. It is unnecessary farther to detail the daily treatment in this 
case. It was found impracticable to prevent more or less air passing into 
the chest, at each operation, and as little or no inconvenience resulted from 
it, under the counteracting influence of the injection, it was no longer 
regarded. The free extremity of the elastic tube was bent downwards 
below the level of that within the cavity, giving to the instrument the pro- 
perties of a syphon, and the whole of the secreted- fluid daily evacuated, 
and the solution of chloride of soda injected, gradually increasing its strength 
and its quantity, until it corresponded with the quantity of matter drawn 
off at each operation. From this time to the 20th of July, when he left 
Columbia, the same course was followed up. The discharge soon lost its 
fetor, and gradually decreased in quantity from the time we commenced the 
use of the injection, so that on his departure it amounted to about three gills 
in the twenty-four hours. 

During this period, a little over a month, his recovery was uninterrupted 
by any untoward symptoms; the state of his digestive organs was carefully 
watched, under the influence of an alterative, tonic course; and as his appe- 
tite and powers of digestion improved, he was allowed a more liberal diet. 
For the last ten days he remained here he was able to take a short walk 
daily, and with much more ease to himself than when he came ; the promi- 
nence of the left side of the thorax, and upper part of the abdomen had sub- 
sided: the heart had made some progress towards the left; but no respiratory 
murmur was yet perceptible on that side. His appetite was good; sleep 
much improved; and when he left me for Cheraw he felt full confidence of 
a speedy recovery. He was advised to continue the same course of treat- 
ment until his health should be restored. 

March 1th, 1837. Dr. M'Queen wrote me that he had passed the month 
of August, after leaving Columbia, at a mineral spring in North Carolina, 
where he derived considerable benefit from the change of air, and the tonic, 
diuretic properties of the water, and farther says, — "Since my return home 
I have been slowly, but constantly improving, and at this time I think my 
general health is as good as it has been for several years. I am as fleshy as 
I ever was — have no cough, no pain — and am able to ride on horseback to 
any distance which I have attempted, without fatigue. I have rode as far as 
twenty miles in a day; my breathing is greatly improved, but the discharge 
still continues; the quantity is small, about a gill every twenty-four hours; 
yet there has been no sensible diminution for the last six or eight weeks. 
The fluid discharged now is, in appearance, very much like what you drew 
off at first; it is without smell, thin and unirritating; the chest on that side 
has fallen in considerably, but is, I think, beginning to expand again. For 
some time past I have discontinued the use of the injection, and indeed of 
every other remedy; but the discharge keeps up so obstinately that I am 
beginning to feel uneasy. Will you add to my debt of obligations by inform- 
ing me what course you would advise to be pursued?" 



1844.] Wells' Surgical Cases, 73 

In answer to this letter I suggested to him to try a weak solution of corro- 
sive sublimate, as an injection into the small cavity still remaining, and that 
failing, to try a weak solution of the nitrate of silver. 

On the 25tli of May, 1837, Dr. M'Queen wrote to me again, that he had 
just recovered from a short attack of fever; that during the fever, the dis- 
charge from his side had considerably increased, and become excessively 
offensive and very irritating. "But I am now," he says, "much better, and 
the discharge has almost ceased; this morning there was only about two 
tablespoonsful, and it has more the appearance of serum than matter." 

In answer to some inquiries which I recently made concerning his present 
state of health. Dr. M'Queen writes me, March 20th, 1844, that the opening 
in his side, and the discharge, continue very nearly the sarne as when he wrote 
in May, 1837. That the left side of the chest is very much contracted, and 
that the ribs on that side are depressed, and he thinks the right side is very 
considerably expanded. This opinion is also expressed by a very intelligent 
medical gentleman who examined him. "The difference in the two sides, 
measuring round the chest from the sternum to the spine, is about four 
inches. This distortion of the chest has caused so much inclination of the 
body to the left, as to make the point of the left shoulder something more 
than two inches lower than the point of the right." There is a slight curva- 
ture of the spine. The heart occupies nearly its natural position in the 
chest. "The respiratory murmur is not heard in the left side; the air never 
enters it. My general health is very good, and I think I may safely say it 
was never better. I take a great deal of exercise without inconvenience; 
am engaged in planting, and attend to my own business without the assist- 
ance of an overseer." 

Remarks. — In paracentesis— an operation which I have performed a great 
many times — I have invariably used a lancet, or a lancet-shaped scalpel, to 
make the opening into the hydropic cavity, whether of the thorax, the 
abdomen, or the tunica vaginalis ; and a catheter with a large eye, either 
metallic or gum-elastic, as the tube through which to draw off the fluid, in 
preference to the unsurgical and awkward trocar and canula; and it seems to 
me that the former have the advantage over the latter, in being more accu- 
rately used by the surgeon, — less painful, as well as less frightful to the 
patient, and certainly, attended with less risk of injury to the contained 
viscera. 

In paracentesis thoracis, for chronic empyema, where the operation has to 
be often repeated, the blunt, elastic tube has other advantages over the trocar 
and canula — it is more readily reintroduced through the puncture— the end 
of the tube introduced may be directed to any part of the cavity without 
danger; and by giving the free extremity a proper curve, as in the above 
case, all the fluid, or nearly all, may be drawn off at any time when that is 
desirable. 

On the contrary, where a simple puncture is made with a trocar, it is diffi- 
cult to keep the orifice open for any considerable length of time, even by the 
introduction of a tent ; and few patients would submit to have the trocar daily 
plunged into the chest for some months, while the cure is being effected. 
But should one succeed, in this way, in establishing a permanent fistulous 
No. XV.— July, 1844. 7 



a£v 



74 Wells' Surgical Cases. [July 

opening in the side, a fungous excrescence is liable to spring up around the 
orifice, attended with morbid irritability and inconvenience. 

Great stress has been laid, by most writers on paracentesis thoracis, on 
the importance of excluding atmospheric air from the thoracic cavity in this 
operation — first, on the ground that the air is an excitant, not adapted to the 
vital properties of serous surfaces ; secondly, that the air would fill the space 
occupied by the fluid drawn off, and thereby prevent the lung, more or less 
collapsed, from re-expanding, and for this reason, the pressure which has 
been applied to the chest during the operation, is directed to he removed as 
soon as the fluid ceases to flow, and the tube is withdraw?!. This is correct 
reasoning, no doubt, in recent cases of thoracic effusion, where the pleura 
has undergone no considerable organic changes, and retains its normal cha- 
racter of a serous membrane, and while the lung is still susceptible of ready 
re-expansion. But in true empyema, like the case of Dr. McQueen, the 
matter is entirely changed. In that case I had a large chronic abscess to deal 
with. The pleura had suffered a deep structural lesion — had lost its charac- 
ter of a serous membrane ; secreting a bland serous fluid, and had become a 
granulated surface; probably in its whole extent, secreting pus. 

The lung had also undergone irreparable organic changes — had become 
atrophied; and its cells nearly, if not entirely obliterated. 

Nothing more then, than a very partial expansion of the lung could have 
been hoped for in this case. 

The indication in chronic empyema, it seems to me, is the same as that 
in other large chronic abscesses — to get rid of the effused fluid, and to close 
the cavity as soon as this can be done without serious functional disturbance 
of the organs of circulation and respiration. A perfect cure is to be effected 
only by an entire obliteration of the pleural sac, by bringing about adhesion 
between the different folds of the pleura. The matter can be drawn off at 
first, to the extent only of the contraction of the thoracic cavity; and to that 
extent I think it may be evacuated at once without danger. The contraction 
of the cavity is to be effected, mainly, from the costal side, by pressure, 
restoring the walls of the chest, which have been more or less pressed out- 
wards, to their natural state,— /rom below, by the action of the abdominal 
muscles, forcing up the depressed viscera and restoring the concavity of the 
diaphragm ; and from the pulmonary side, by the expansion of the lungs. 
Now what would be the result of abstracting a considerable quantity of mat- 
ter from the chest, by pressure upon the diseased side, and as soon as the 
opening into the cavity should be closed, removing that pressure? The 
elasticity of the ribs, tfec. would, of course, restore them to the state in which 
they were before the operation, and unless the space occupied by the matter 
withdrawn, should be filled from below by the elevation of the diaphragm, it 
must be supplied from the opposite side by the increased expansion of the 
lungs. But in true empyema, when the tissue of the lung in the diseased 
side has undergone changes incompatible with re-expansion — and this, I 



1844.] Wells' Surgical Cases, 75 

apprehend, would be found to be the state of things in most cases of em- 
pyema, where an operation is called for — then this tendency to a vacuum 
would be counteracted by the increased and permanent dilatation of the sound 
lung. This, of course, could be endured only to a very limited extent, 
without endangering life from suffocation — the ability to make an expiration 
sufficient to renew the air in the lung would be lost. This was the condition 
of my patient after the second operation, when the pressure was removed 
from the chest for a few seconds — and should always be guarded against by 
keeping up such a degree of pressure, as shall secure the proper action of the 
sound lung. It is true, that all means should be used to restore the function 
of the collapsed lung — so far as this may be practicable— and the most ready 
way of doing this, would be the production of a partial vacuum on that side ; 
and the extent to which this may be carried sho Id be measured by the 
degree of embarrassment in the function of the sound lung, which may be 
borne without danger. 

Is the admission of pure atmospheric air to the cavity of a chronic abscess, 
directly injurious? I suppose the experience of most surgeons of the pre- 
sent day, would not only answer this question in the negative, but say that 
the free admission of pure air, in such cases, \s decidedly beneficial. In the 
treatment of a chronic abscess, where the contents are morbid, attended with 
great constitutional irritation, every surgeon knows how soon this state of 
the system is changed for the better, by freely laying open the cavity — 
where this is practicable — and giving free access to the air and light. The 
walls of the abscess on being exposed, are found coated with a thick, dirty, 
tenacious secretion, which can scarcely be removed by washing with a 
sponge and water — the effused lymph is but imperfectly organized — and the 
granulations, so far as they are formed, are pale and flabby — a peculiarly 
morbid condition of the secreting surface, incompatible with the secretion of 
healthy pus, and deeply implicating the sympathies of the system. In a 
very few days after free incision, by simple water dressings, or the applica- 
tion of some of the chlorides and lint, the cavity is cleansed, the granulations 
become healthy and secrete pure pus, and the constitutional irritation disap- 
pears. This alleviation of the constitutional disturbance, could be effected 
only by bringing the secreting surface of the abscess into a healthy condition ; 
and this, in many cases, could not be brought about by any treatment, local 
or general, short of free incision and exposure of the entire cavity: on the 
contrary, the constitutional irritation is not unfrequently aggravated, to a dan- 
gerous degree, by simple puncture and partial or complete evacuation of the 
abscess.* The hectic and its concomitants, supervening upon the discharge 
of the matter in such cases, have been wrongfully attributed to the admission 
of air to the cavity of the abscess, even where the walls of the abscess neces- 
sarily collapse as the matter is discharged, and when not a particle of air 

* See the next ease. 



76 Wells' Surgical Cases. [J "^7 

could gain access to the cavity. This aggravation of the constitutional symp- 
toms may, I think, be accounted for vi^ithout resorting to this air-hypothesis. 
In cases complicated by irremedial organic lesions, as in psoas abscess, 
originating in caries of the spinal vertebrae, where the medulla spinalis has 
begun to suffer, the constitution is already worn down, the remedial powers 
of nature are exhausted, and the least shock given to the system, from what- 
ever cause, is most sensibly felt, and may hasten on a fatal termination. 
These cases are among the inmrables, and may be dismissed. 

It seems to be a law of granulating surfaces, when brought into contact, if 
in a healthy state, to adhere and close the breach; but when in a morbid con- 
dition, if brought into near proximity, the vital action of the part is still 
farther disturbed, and consequently the secretions become more and more 
vitiated, implicating the constitutional sympathies to an extent, compared 
with the local affection, not always easily accounted for; and to this law of 
our organism should mainly be attributed, I conceive, the evils which some- 
times follow the opening of large abscesses, and not to the admission of air 
tO' their cavities. At all events, the constitutional disturbance is relieved by a 
course of treatment, which restores healthy action to these secreting surfaces; 
let it be by free incision, by stimulating injections, often repeated, filling the 
cavity, and suffering the injected fluid to remain from one time to another — 
or by filling the cavity widi lint, wet with some detergent liquid, and thus 
protecting these surfaces against their own vitiated secretions^ and preventing 
them from coming in contact with each other. I have frequently succeeded 
in treating chronic inguinal and pelvic abscesses, unaccompanied with lesion 
of the osseous tissue, in this way; and it is still to be shown that, distending 
such cavities, after cleansing them by proper m}ect\ons, with atmospheric air^ 
to be renewed at intervals sufficiently limited to guard against deleterious 
changes in the air, would not be sound practice in abscesses involving parts 
not admitting of incision. 

The admission of air, then, to large cavities secreting pus, is to be dreaded 
only from the pernicious changes it induces in the contents of such cavities ; 
and, I apprehend, the resources of surgery will be found amply sufficient to 
guard against these. 

The chlorides, especially that of soda, seem to possess the property of 
counteracting the unfavourable influence of the air upon purulent secretions, 
while at the same time they improve the condition of the secreting surface ; 
and no doubt, solutions of iodine will be found efficient in the latter particu- 
lar — always, of course, relying very much upon constitutional treatment in 
cases of the kind. 

One word farther in reference to the operation for chronic empyema — I 
would advise, after deciding upon the place where the puncture should be 
made, to commence by an incision, an inch and a half in length, through the 
integuments, close upon the upper edge of the rib selected, and then to thrust 
the scalpel at once, through the muscles and pleura. There can be no good 



1844.] Wells' Surgical Cases. ' 77 

reason for dissecting down to the pleura, before puncturing that membrane, 
as recommended in a late and excellent work on surgery. An ample inci- 
sion through the integuments at first, will enable the surgeon, by dressing 
with cerate and a tent, to obviate the necessity of repeating the puncture. 
The elastic tube may be easily introduced through the puncture — firm and 
steady pressure should be made upon the aff'ected side by a bandage around 
the chest, and the matter allowed to flow until some embarrassment in the 
respiration and circulation is experienced. The operation should then be 
suspended, until the system accommodates itself to this change in the con- 
tents of the thoracic cavity, aided by the continued pressure of the bandage. 
In twelve or twenty-four hours, the operation may be repeated, and so on, 
until all the fluid shall have been withdrawn. When the quantity of matter 
is large, the disturbance of the functions of the thoracic viscera, from its dis- 
charge, will of course be very considerable at first, and should not be 
increased by any avoidable impression. It would, therefore, be best to pre- 
vent, as far as practicable, the admission of air to the pleural sac, for the first 
four days, until the walls of the thorax are brought back to their normal 
state, and the heart and lungs accommodate themselves to this new state of 
things, so far as to admit of the abstraction of the whole of the fluid. After 
that, when it comes to the daily discharge of the daily secretion, no evil need 
be apprehended from the admission of air; indeed, this will be found una- 
voidable. At this period, I would commence injecting, and even earlier, 
should air have accidentally gained admission to the pleural sac, which will 
be known by the fetid smell of the sulphuretted hydrogen gas generated. 

These were my views of the pathology and treatment of chronic empy- 
ema, at the time of treating the above case, nor have I, on more mature 
reflection and experience, had reason to change them. I am happy to find 
them nearly in accordance with those of the eminent Parisian surgeon, 
M. Velpeau, as laid down in his Medecine Operatoire, a work, which I did 
not see until some time afterwards. The treatment of empyema, by deter- 
gent injections, is also recommended in certain cases, in an able article by 
Dr. Williams, in Tweedie's Library of Practical Medicine, published in 
Philadelphia in 1841. 

Case II. — Injury of the thigh — Rupture of the Gracilis muscle — exten- 
sive effusion — Treated, in a chronic state, by incision — Cure. — I was called, 
Aug. 4th, 1826, to see Henry, a black man, of robust constitution, aged about 
30 years, belonging to J. T. Wade Esq., residing in the country, about five 
miles from Columbia, who had, while engaged in felling trees, been accident- 
ally caught under a falling tree, and badly injured. 

The superior maxillary bones were fractured in three places ; the inferior, 
in two places ; the front teeth, together with the corresponding alveolar pro- 
cesses, were detached from the lower jaw; the soft parts of the face cut, and 
shockingly lacerated ; his right thigh was bruised and swollen, but the skin 
not broken. On my arrival, a few hours after the accident, he was still suf- 
fering from concussion of the brain, and the general shock given to his sys- 



78 Wells' Surgical Cases. '[July 

tem. The wounds of the soft parts of the face were dressed with sutures 
and adhesive straps-^the fractures adjusted, and the bones kept in place, by 
ligatures passed around the teeth in the different fragments, and firmly tied, — 
by a pasteboard splint, softened and moulded to the shape of the lower jaw, 
and a bandage applied, so as to keep the corresponding teeth in the upper 
and lower jaw, in contact. 

The injury of the head claimed our whole attention, and little was thought 
of the injury of the thigh, of which he scarcely complained. 

The next day he had recovered from the shock, was able to walk about, 
and nothing seemed to be required, but time, to allow the bones to unite. 
There was no difficulty in insuring an antiphlogistic regimen, as nothing 
could be gotten into his mouth, except fluids, through the opening left by the 
loss of his front teeth. 

Every thing went on favourably until the 20th of August, when he was 
brought into town, complaining principally of his thigh, which was very 
much swollen, and had become mflamed and painful within the last few days. 
On examination it was evident that there was a large quantity of fluid col- 
lected in the thigh, under the fascia, extending from the knee to the groin. 
I made a puncture with a broad lancet on the inside of the thigh, an inch 
above the condyle, and drew off between three and four pints of serous fluid 
slightly tinged with blood, which gave him immediate relief from the pain. 
This fluid, on standing a short time, coagulated into a thin jelly. A roller 
bandage was applied to the thigh as tightly as it could be borne without pain, 
in hopes the cavity might be closed by adhesion. 

22d. He began to suffer severe pain again in the thigh, from the accumu- 
lation of fluid, and it was found necessary to use the lancet again for its dis- 
charge. About two pints were drawn off similar to the first discharge. The 
cavity was injected with a stimulating fluid, a tent introduced into the 
puncture ; the bandage reapplied, and alterative medicine administered inter- 
nally. 

This treatment was continued for the succeeding fifteen days, varying the 
injection repeatedly, in hopes to bring about adhesive inflammation in the 
cavity. The discharge soon became sero-purulent, from six to eight ounces 
a day, and a most violent hectic fever was lighted up in his system, the 
nightly paroxysm terminating in a profuse sweat. The constitutional dis- 
turbance increased daily, until he had an utter loathing of every thing in the 
form of nourishment; frequent turns of nausea, and efforts to vomit; the 
pulse became very quick and small; was exceedingly restless ; got no sleep, 
except when under the influence of a strong anodyne; there was a rapid 
emaciation ; his eyes were sunken, and his features disturbed. 

This was his condition on the 7th of September, a state of constitutional 
irritation greater than I have since met with in any case, and when it 
appeared he could not live much longer without some change in his case, I 
introduced a bistoury through the puncture into the cavity, and made an inci- 
sion between eight and ten inches in length, on the inside of the thigh, in 
the course of the gracilis muscle. There was no appearance of living 
tissue in this exposed cavity — the whole surface was of a dirty, ashy colour. 
It w^as found that the gracilis muscle had been ruptured at its inferior extre- 
mity, and, that the lower half of the muscle was in a state of decomposition, 
nothing remaining of it, but shreds of cellular membrane ; the cellular tissue 
throughout the cavity, was in a state of disorganization. 

The cavity was filled with lint wet with port-wine, and a light bandage 
passed around the thigh. The same constitutional treatment was continued. 



1844.] Wells' Surgical Cases. 79 

From tliis moment his symptoms began to improve ; in the course of three 
days the coating of the entire cavity was thrown off, and the surface assumed 
a healthful granulating appearance ; his sleep was restored ; the bark and 
wine, with which he had been liberally supplied, now acted as a cordial; his 
appetite returned, and the hectic paroxysms gradually disappeared. This 
convalescence was uninterrupted; in the course of four weeks, the wound in 
the thigh had nearly cicatrized, and he was walking about. 

Henry's recovery was complete, and he continued to enjoy the perfect use 
of his leg for ten years thereafter, but since that period, say for the last six 
or seven years, this leg has gradually failed him, when exposed to hard 
labour, and is subject to attacks of oedematous swelling, two or three times 
in the course of the year. I examined his thigh a few days ago, for the first 
time since fifteen years. The cicatrix, resulting from the incision on the 
inside of the thigh, has contracted longitudinally, to about one-half its ori- 
ginal length, and in its middle, seems attached to the deep-seated parts, 
leaving a considerable fissure in that part of the thigh; he is otherwise in 
good health. 

Remarks. — This was an extreme case of constitutional irritation, super- 
vening upon the opening and discharge of the contents of a large cavity, 
differing in no essential particular, as I conceive, from ordinary chronic 
abscess. The treatment, local and general, seems to have been such as was 
sanctioned by surgical writers of that day; the cavity was injected with 
solutions of the sulphate of zinc, sulphate of copper and the oxy-mur. 
hydrarg.; calomel, opium, bitter, alkaline, aperient infusions, bark and wine, 
&;c., were freely administered internally, with a view of allaying irritation and 
restoring a healthy state of the secretions. Notwithstanding, from an error 
in judgment, in continuing my efforts to close the cavity by this treatment 
so long before resorting to the only proper means in the case, my patient 
came very near losing his life- — a sin in practice, of which I have not since 
had cause to repent. 

Case HI. — Extensive Disease of the Tibia — Removal of nearly one-third 
of the Shaft of that bone — the bone reproduced and limb preserved. Henry 
Lee, a free, light mulatto man, aged 38 years, five feet ten inches in height, 
well made, of sound constitution, a carpenter by trade, industrious, and of 
good habits, was attacked with bilious remittent fever on the 2d or 3d of 
November, 1840. For the first week he attempted to treat himself, and 
took several doses of cathartic medicine. When I first saw him, on the 
fifth or sixth day of the attack, he was dangerously ill; his vital forces were 
much exhausted ; his skin deeply tinged with bile, as was more especially 
seen by the deep yellow colour of his eyes and mucous membrane of his 
mouth; only partial remission of the fever; the brain oppressed, with a ten- 
dency to coma; pulse quick and weak; tongue thickly covered with a dark 
coat in the centre, dry and shining at its edges. He lay almost altogether 
upon his back, limbs extended, and took little notice of any thing about him. 

For a week after he came under my care his recovery was considered very 
doubtful; after that the symptoms gradually improved until the 25th of No- 
vember, when he was considered fairly convalescent, and I discontinued my 
visits. 

On the 12th of December following 1 was called to see him again, and 



80 Wells' Surgical Cases. [July- 

found him in the following condition. He was suffering great constitutional 
irritation, with hectic exacerbations at night; the right foot and leg immode- 
rately swollen and oedematous; the skin and cellular tissue, on the inner 
side of the leg, were entirely destroyed for six inches, from a point about 
three inches above the ankle-joint upwards, and involving about one-third of 
its circumference, from a line three-fourths of an inch external to the crest of 
the tibia, leaving the inyier surface of that bone bare and black to the full 
extent of the ulcer, longitudinally ; the muscles were partially detached from 
its anterior and inner edges. There were some excavations upon the surface 
of the bone, w^hich had the appearance of having been caused by ulceration, 
or the application of some corroding agent. 

On inquiry I found that liCe had received a slight injury on the shin some 
days before he was taken down with the fever, but the breach in the skin 
was soon healed, and he thought no more of it. On the 5th of December, 
however, ten days after I had discontinued my visits, inflammation super- 
vened at the point where he had received the injury-, which soon ran into 
ulceration, and the surrounding skin became dark-coloured. An officious 
friend calling to see Lee, persuaded him to apply, as an infallible remedy for 
"sore shins," "Cheeseman's Arabian Balsam." This application was fol- 
lowed, in the course of two days, by sloughing of the soft parts to the extent 
above mentioned, leaving the tibia exposed. What was the active ingredi- 
ent in this Cheeseman's Balsam I know not, as I was not able to procure 
any of the article for examination, nor am I able to say with certainty 
whether that was the cause of this rapid and extensive destruction of the 
parts: or this, the result of injlammation and gangrene, under a disturbed 
state of the system, although I am inclined to attribute some part of the 
mischief to that application. 

The process of separation, between the dead bone at each extremity and 
that still covered with integuments, had already made considerable progress, 
especially at the lower end, so that I had no doubt the entire shaft of the 
tibia was deprived of vitality. 

The question now to be decided, was between immediate amputation and 
an attempt to save the limb, in the hope that nature, in her abundant re- 
sources, might, in some way, fill up this extensive breach in the tibia, either 
by ossific deposits, or some substitute which would give firmness to the leg, 
without which it would be worse than useless. My decision was in favour 
of the latter course, on the ground that the periosteum, on the under surface 
of the bone, might remain intact, and that ossific deposit might take place 
in the granulations, which would necessarily shoot up from this membrane, 
and the tibia thus become again united. In coming to this decision I was 
aided by general principles alone— I knew of no precedent: nor am I now 
aware of any parallel case having been recorded. 

The ulcerated surface was covered with a fold of lint saturated with a 
solution of the chloride of soda; over this a roller bandage from the toes to 
the knee; a separate strip over the diseased surface for the convenience of 
dressing; a hollow splint was carefully adjusted to the outside of the foot 
and leg, and the leg kept constantly in a horizontal position. Lee was put 
upon an alterative, tonic course of treatment. At first he took a pill com- 
posed of blue mass and ext. cicuta, aa gr. ii, a iii, every night, and three or 
four times through the day, a small glassful of a decoction of gentian, orange 
peel, rhei, and sup. carb. soda, sufficient to procure a regular motion of the 
bowels daily; an anodyne draught at night to procure sleep, and was allowed 
a simple but nutritious diet. In a few days his condition w^as much im- 



1844.] Wells' Surgical Cases. 81 

j)roved; his appetite became good, and his sleep natural. From that time 
his recovery was constantly progressive. This course of treatment was 
followed up, with more or less regularity, for four or five months, occasion- 
ally substituting for the bitter decoction quinine, porter, wine and other 
tonics. Indeed, he has been obliged to resort to this alterative course occa- 
sionally, for a few weeks at a time, up to the present moment, whenever his 
digestive apparatus failed in its healthful action. 

On the 19th or 20th of December, one week after I was called to see Lee, 
a complete division of the tibia below had taken place, and the foot, still 
much swollen, when unsupported, would fall backwards or outwards, almost 
as much as in complete fracture of the leg at this point, so great was the 
destruction of the tissues of the leg, and so little was the support afforded by 
the fibula. Great care was required, at all subsequent changes of the dress- 
ings, in steadying the foot. Early in January it was clear that separation had 
taken place also at the upper extremity of the dead bone, but it was not thought 
advisable to attempt its removal, or in any way to disturb it, for fear of inter- 
rupting the process going on beneath, until the middle of February, when 
this section of the tibia was quite loose, and easily detached from its con- 
nections with the granulations, which had penetrated into the innumerable 
small openings made by absorption, in its extremities and under surface, 
giving It the appearance of having been worm-eaten. The discharge of 
blood from the lacerated granulations was copious for a few moments, but 
this was very soon arrested by the application of cold water. The length of 
bone removed had been very considerably reduced by absorption. At this 
time cicatrization of the soft parts had reached very near to the edges of the 
tibia on either side. The division in the tibia was not transverse, but oblique 
from its centre, so that there may have been near an inch of some laminae of 
the posterior surface remaining, both above and below. 

From this time on, the local treatment was directed to the support of a 
healthy state of the granulations in this cavity, which went on slowly, but 
progressively filling up. 

On the 7th of April it was found that ossification had made considerable 
progress, sufficient to give steadiness to the foot in rotating the limb; and 
Lee, still wearing the same dressings, was allowed, for the first time, to 
mount his crutches and take a little exercise about his room. In a few weeks 
after he was able to go into his garden; and on the 4th of July following he 
could bear his weight upon the leg. From this time he rapidly regained his 
flesh and strength, and about the 1st of October, ten months from the necrosis 
of the tibia, he began to do something at his trade again, but did not regain 
the full use of the limb until July, 1842. Since this last date he has been 
regularly at hard work, and has enjoyed good health. For three months 
during the last summer he was engaged in building a bridge, in the river 
swamp below Columbia, where he had to labour, a great part of the time, in 
mud and water up to his waist. For the last eighteen months, during which 
time Lee has called on me only once in two or three months, cicatrization of 
the remaining ulcer has advanced very slowly, and apparently in a corre- 
sponding ratio with the filling up of the cavity left by the removal of the 
necrosed bone. 

I have, within a few days, made a careful examination of Lee's leg. There 
still remains an ulcerated surface, three and a half inches long, and in the 
centre something more than an inch broad, gradually contracting from this 
point upwards and downwards. The granulations appear healthy, and 
secrete a very moderate quantity of pus. The new bone formed is about 



82 Wells' Surgical Cases. [Jw^y 

half the original thickness of the tibia, and something broader; a little more 
elevated at its margins, which are covered with new skin, than in the middle. 
On introducing an acupuncture needle at different points of this ulcer the 
bone is found to be exceedingly hard, not admitting the point of the needle 
to penetrate it at all. There are distinctly felt by the needle minute spiculae 
of bone shooting up into the granulations from the solid bone below. 

The extremity of the superior portion of the tibia next the ulcer is very 
considerably enlarged, and has been extended downwards, by ossific deposit, 
an inch or an inch and a half; the superior extremity of the loioer portion 
is much less enlarged, and has increased upwards not more than half an 
inch. The depression or cavity remaining is about half an inch below the 
level of the original bone, but when a line is drawn from the enlarged ex- 
tremities of the bone above and below, it shows a depression in the centre of 
three-fourths of an inch or more. The filling up of this cavity with ossific 
deposit has gone on pretty regularly, rather faster in the central portion, if 
any thing, than at either extremity, so tliat the cavity- now approaches nearer 
a plane than at first. The process of ossification is evidently still going on, 
and I am inclined to believe that the original thickness of the bone will be 
nearly, if not quite, attained. 

A great many changes have been made in the local applications to this 
ulcer, to preserve a healthy state of its granulations, principally selected 
from the mineral solutions and chlorides; the one, however, wjiich seems to 
have retained its character the longest, is an ioduretted mercurial unguent, 
according to the following recipe: — R. Iodine, gr. xv; hydriod. potass., Bii; 
ungt. mercurial., ungt. resinos., aa 5ss.— M. ft. ungt. 

I may have attached too much importance to this case, and been unneces- 
sarily minute in describing it; but, if I am not mistaken, it is calculated to 
throw some light upon the process of reproduction of bone- — a subject by no 
means exhausted, and may encourage the young surgeon to persevere in his 
eflforts to preserve his patient from mutilation in similar cases. 

The specimen of bone removed in the above case is in the possession of 
my friend, Dr. W. Parker, the able professor of surgery in the College of 
Physicians and Surgeons in the city of New York. 

Case IV, — ^n enormous encysted Tumour developed in the upper part of 
the Thigh. Treated by incision, discutient applications, bandage, Sfc. — 
Cure. Mr. E. Hartzoge, of Lincolton, N. C.,aged 25 years, of low stature, 
but thick set and stoutly built, came to Columbia for professional aid, Feb. 
15th, 1842, on account of an enormous tumour, attached to the upper and 
inner part of the left thigh. 

The tumour approaches nearly to a globular form, commencing near the 
superior anterior spinous process of the ilium, extending inwards in the 
course of Poupart's ligament, to the pubis, thence backwards to a point a 
little below the tuber ischii; and when he stands erect, hangs down some 
inches below his knees. The following are the dimensions of the tumour 
when in the standing position. A line passed vertically around it, from its 
upper attachment in front, a little above Poupart's ligament, to its upper 
posterior attachment, an inch below the tuber ischii, measures three feet and 
five inches : a line passed in like manner horizontally over its greatest diame- 
ter, from its anterior to its posterior attachment to the thigh, three feet and 
four inches, giving a mean circumference of about four feet. The pendulous 
part of the tumour when he is sitting upon a common chair, the leg being 
flexed to a right angle with the thigh, reaches nearly to the ground, and is 



1844.] 



Wells' Surgical Cases. 



83 




three feet and one inch 
in circumference. In 
this position its attach- 
ments involve the two 
upper thirds of the 
thigh, but when in the 
standing position, the 
skin is drawn from the 
thigh over the tumour 
to within two inches of 
the knee. To the touch 
the tumour is firm and 
elastic, its surface is 
regular and smooth, ex- 
cept that it is traversed 
in several places, by 
enlarged, tortuous va- 
ricose veins. The veins 
over the pubis and 
across to the ilium, are 
also greatly enlarged 
and varicose. The sar- 
torius and gracilis 
muscles are disiinctly 
felt passing over the 
inner surface of the 
tumour; and there may 
be other muscles in- 
volved in its walls, but 
if so they cannot be 
distinctly traced. 




84 Wells' Surgical Cases. [J'^ty 

When standing, his knees are widely separated and bowed outwards, and 
his feet about eighteen inches apart. He walks with difficulty; his counte- 
nance indicates much constitutional disturbance and anxiety; and although 
only twenty-six years old, he might be taken for forty-five or fifty. He is 
very much emaciated; pulse quick and weak; appetite and digestion bad ; 
bowels disposed alternately to diarrhoea and constipation. 

Mr. H. gave us the following history of his case. He says, " up to my 
eighteenth year I enjoyed remarkably good health, was stout and athletic ; 
weighed at that age 155 lbs. About that time I was attacked, after a very 
hard day's labour in the harvest, with violent pains in my legs ; supposed 
by my physician to be rheumatic; was confined to my bed for a week. I 
then got better; the pain left my right leg and settled in my left thigh. In 
about three weeks after this, a large abscess formed in the upper part of the 
thigh and groin ; this was opened, and a large quantity of matter discharged 
at the time ; there was more or less discharge from this opening for three 
months afterwards, when it healed; but the parts continued ever after sore to 
the touch. No bone was discharged from the abscess. Soon after this 
abscess closed, two others were formed, one on the back part of the right 
shoulder, the other over the anterior extremity of the second rib of the same 
side, from both of which, ten or twelve weeks after they were first opened, 
small pieces of bone were discharged. These attacks confined me to my 
house for twelve months ; and for two years after that I was obliged to 
walk on crutches ; my general health, in the meantime, gradually improving. 
I then went to the shoemaker's trade, and very soon thereafter, discovered a 
swelling at the upper and inner part of the thigh, which has gone on increas- 
ing regularly from that time to this — nearly six years — the result is what 
you see. I suffered little or no pain from this swelling, until within the last 
eighteen months; since that time I have experienced great difficulty from the 
weijjht of the tumour, in taking exercise, either in walking or riding; and 
when I have attempted it, have felt great fatigue and pain. My health has 
been constantly declining, and unless I can get relief, I cannot stand it much 
longer." 

Hartzoge was put upon an alterative, tonic course of treatment, consisting 
of some grains of blue mass and ext. cicuta at night, and a small glassful of 
a bitter, alkaline, aperient infusion several times through the day, sufficient 
to procure a regular motion of the bowels daily, and confined to a very simple 
diet. This course was continued between two and three weeks, until the 
abdominal secretions were brought into a more healthy state, before any local 
treatment was attempted ; being in doubt in the mean time, whether any 
surgical procedure were admissible in the case. 

On the 3d of March, an exploring needle was introduced into the inner 
face of the tumour, to the depth of two or three inches, and some drops of a 
viscid fluid made their appearance. The character of the tumour was thus 
revealed to us, and it was thought advisable to try the efTect of drawing off 
the fluid contents. A large trocar was accordingly thrust through its walls 
near the point where the exploring needle had been introduced, and between 
three and four gallons of a thick albuminous fluid drawn off; a broad bandage 
was applied around the thigh and the immense mass which remained, so as 
to afford some degree of pressure, and the result awaited. Little or no con- 
stitutional disturbance or inconvenience followed this operation, except for 
the first few days; he found it difficult to stand or make a step upon the floor, 
when he got out of bed, having "lost his ballast." It was soon discovered, 
however, that nothing was to be gained by this process. The cavity in the 



1844.] ' Wells' Surgical Cases, 85 

tumour filled up again rapidly, so that in ten days it had attained its original 
size, and he felt his strength considerably reduced. 

March I3th. It was now determined to make an attempt to relieve our 
patient of his monstrous incumbrance, although at the risk of serious conse- 
quences. A free incision was made through the walls of the tumour, upon 
its inner face, and about two gallons of fluid discharged, similar to that first 
drawn off, only rather more viscid. The hand was then introduced into the 
cavity, and a considerable quantity of a jelly-like matter removed, together 
with two pieces of bone, one of which had the appearance of a detached 
portion of one of the trochanters, the other was a segment of a ring an inch 
broad, and was supposed to be an exfoliation from the femur. The remains 
of the tumour nov/ lay spread out upon the bed, an enormous, flabby mass, 
from four to six inches in thickness; the walls of the tumour being of un- 
equal thickness in different parts. To the feel, when the hand was intro- 
duced into the cavity, it was not unliice an imperfectly contracted uterus 
immediately after the expulsion of the child. 

A bandage was applied, moderately tight, over the thigh and tumour ; his 
bowels attended to; his diet very simple; and the symptoms carefully 
watched in anticipation of the inflammation, which was not slow in declaring 
itself. At first the discharge from the interior of the tumour was copious, 
but this gradually decreased, and on the third day had nearly ceased; a 
serous infiltration had taken place into the parietes of the tumour, attended 
with considerable swelling and oedema of the whole mass, and the integu- 
ments were involved in an erysipelatous inflammation. From this time to 
the 20th of March, the state of our patient was any thing but encouraging ; 
the swelling continued to increase ; the inflammation became more and more 
violent, and the constitutional disturbance alarming; the symptoms which 
supervened were not unlike those of a bad case of strangulated hernia. He 
complained greatly of the pain through the tumour, the thigh, and the lower 
part of the abdomen ; bad vomiting, hiccup, and spasms of the abdominal 
muscles and bowels ; pulse rapid, and respiration somewhat embarrassed. 
At first, to moderate the external inflammation, cold water and other refrige- 
rants were applied freely to the inflamed parts, but as the inflammation 
increased, we made use of a strong solution of the sulphate of iron, by means 
of folds of lint soaked in this solution, kept constantly applied to the entire 
external surface of the tumour, as advised by M. Velpeau in the treatment of 
erysipelas. This application had a most happy effect in moderating the 
external inflammation. 

The constitutional symptoms were combated with calomel, morphine, and 
camphor — fomentations to the abdomen, &c., and were found amenable to 
that treatment. In the evening of the seventh day after the incision was 
made into the tumour, it had regained considerable rotundity ; there had been 
no discharge from the cavity for three days, the incised parts having become 
agglutinated together; and when the state of our patient was at its worst, a 
blunt instrument was forced into the cavity, the wound reopened, and a quart 
or more of purulent matter discharged. This gave him immediate relief 
from the pain, of which he principally complained ; he had some hours of 
sound sleep ; the severity of all the symptoms gradually abated ; the inflam- 
mation decreased, and the febrile excitement subsided. For the next eight 
or ten days, suppuration went on freely within the cavity ; there was a 
copious, thin, purulent discharge, which kept every thing about him saturated; 
there were two or three points of sloughing through the walls of the tumour 
and the entire lining of its cavity, seemed to be thrown ofTin patches, some 
XV.— No. July, 1844. 8 



86 Wells' Surgical Cases, [July 

of the size of the palm of the hand. The solution of the sulph. ferri was 
continued externally, and the cavity daily injected with a solution of the 
chloride of soda. On the first intermission in his fever, he commenced 
taking quinine and wine, and was allowed as free a diet as the state of his 
stomach would admit. For fifteen or twenty days previously, he had taken 
very little nourishment. About the first of April he was nearly clear of fe- 
brile excitement, the inflammation and soreness had left the tumour, the size 
of which had been very considerably reduced by suppuration ; his appetite 
was moderately good. 

From this time he took full doses of quinine and hydriodate of potass, 
alternately, a dose of each two or three times a day ; the abdominal secre- 
tions were carefully attended to, and when restless and indisposed to sleep at 
night, which was frequently the case, a dose of morphine was given him. A 
little wine and a liberal diet were now allowed. The local treatment was 
now also changed; an ioduretted mercurial unguent was freely rubbed upon 
the entire surface of the tumour every morning, and- the cavity injected, as 
before, and the whole subjected to the pressure of a well-adjusted bandage 
applied with as much firmness as could be borne without pain. 

The process of absorption from the commencement of this treatment was 
astonishingly rapid ; his strength and spirits, which had been miserably de- 
pressed, soon began to improve. After the 10th of April, he sat up a short 
time every day, and towards the last of the month could walk about his 
chamber. May 1st, he put on common pantaloons of a large size, and rode 
out in a carriage ; this was afterwards daily followed up. During the latter 
part of his stay here, several considerable collections of matter formed in the 
atrophied walls of the tumour, and were laid open, but these were attended 
with very little pain or inconvenience. 

On the 20th of May he was able to walk very well ; his thigh with the 
bandage on, was about twice the size of the other; he was directed to follow 
up the same course of treatment for some months, until his thigh should be 
reduced to its natural state, and his general health restored ; the next day he 
left Columbia for his home in North Carolina. Nothing occurred after he 
left here to interrupt convalescence; three months after his return home, he 
wrote me that his thigh was of the same size as the other, and he " was a 
well man again." 

In July last, he wrote me again, that he still enjoyed excellent health, had 
no trouble with his leg, and had returned to his trade again. I have recently 
heard that he continued to enjoy excellent health, and had the full use of his 
left leg, in ^very respect as well as he ever had. 

In the treatment of this case I was aided by Dr. S. Fair, my associate in 
practice, and the treatment was witnessed by four other members of the 
faculty of this city. 

Remarks. — There seems to have been something out of the ordinary 
course of pathological changes, in the origin and progress of this case. 

In the first attacks mentioned in the history of Hertzoge's sufferings, there 
was undoubtedly inflammation and necrosis of a portion of the upper extre- 
mity of the femur, followed by abscess ; this, however, closed before the 
dead bone was thrown off, and when exfoliation did take place, instead of 
the detached portions of bone being discharged by ulceration, the common 
course in such cases, the vital properties of the surrounding tissues had be- 



1844.] Boling on Inflammatory Affections of Malarious Districts. 87 

come so modified, that a sack was formed around these foreign bodies ; this 
sack, to protect itself against irritation, became a secreting surface ; and as 
the secretion increased and distended the sack thus formed, this, and the 
adjacent tissues took on the process of hypertrophy, and thus the secretion 
and hypertrophy went on pari passu. 

In reference to the treatment of the case, it may be a question whether 
the course pursued was the best and safest for the patient or not ? whether 
it would not have been better to have removed the whole mass at once with 
the knife ? I thought otherwise. 

Its removal would have given a severe shock to the system, already greatly 
deranged in every function ; but had he survived this, the disturbance in the 
circulation, under the excitement which would necessarily have followed such 
an operation, and the exposure of such an extent of surface upon the lower 
part of the abdomen, perineum, and thigh, would have disposed to organic 
changes in other parts of the system, destructive to life. As it was, we 
were seriously apprehensive for some weeks that his lung might suffer. 

It may also be a question, whether the risk which our patient ran, and 
which was undoubtedly considerable, might not have been lessened by differ- 
ent management of the case; during the week, sul^equent to the incision 
being made in the tumour, and especially during the last three days of that 
period, while suppurative inflammation was going on in its interior? The 
inflammation and pain would, undoubtedly, have been moderated, and con- 
sequently the constitutional disturbance lessened, by keeping the incision 
open, and by injecting tepid water or mucilage into the cavity ; but it was 
thought desirable that a considerable degree of inflammation and suppura- 
tion should be induced in this cavity, sufficient to essentially change the 
organic action throughout the whole mass ; and farther I can only appeal to 
the result. 

This case shows that enormous abnormal productions may be removed, 
under favourable circumstances, by the natural powers of the system, aided 
by means at the command of the enlightened surgeon. 

Note. — This tumour, from its solid contents, must have weighed between 
60 and 70 pounds. 



Art. V. — On the Treatment of the Inflammatory Jlffections of Malarious 
Districts. By Wm. M. Boling, M. D., of Montgomery, Alabama. 

A PECULIARITY of the febrile excitement produced in the system by, and 
accompanying local inflammations in those residing in marshy districts, is, 
that it has a tendency to assume the intermittent or remittent type, as mala- 
rious fevers not connected with local inflammations have. Mostly, however. 



88 Boling on Inflammatory Affections of Malarious Districts, [July 

the fever is remittent, and of the quotidian, tertian or double tertian type. 
So striking is this resemblance in type between the fevers excited by the 
phlegmasise, and the uncomplicated remittent fever, that doubts must often 
arise, as to whether the fever is the consequence of the local inflammation, 
or the local inflammation merely an accidental concomitant of the fever. 

In many instances, local inflammations are preceded, in malarious dis- 
tricts, by a stage in which the affection is purely neuralgic, and generally 
remittent, and it is only after several of these neuralgic exacerbations, that 
the sanguiferous system becomes so implicated, as to constitute what is 
understood by the term inflammation. Sometimes the neuralgic exacerba- 
tions are accompanied by slight febrile paroxysms ; sometimes the febrile 
excitement only supervenes, as the inflammatory character of the complaint 
becomes developed. 

Another striking peculiarity about these inflammations, is the obstinacy 
with which they resist what is generally considered a purely antiphlogistic 
treatment, — a treatment that would be in most cases speedily successful in 
the phlegmasiae of those living in an atmosphere untainted with malaria, — 
and the facility with which, as a general rule, they yield to a course of prac- 
tice, applicable, in its peculiar features, to the treatment of the uncomplicated 
fevers of the same regions. The fatality of these aflTections, for instance, of 
the disease generally known as bilious or typhoid pneumonia, under a purely 
antiphlogistic treatment, (by this I mean bleeding, tartar-emetic, purging and 
blistering) or under a systematic exhibition of mercurials ; or under another 
system of treatment pursued by a few physicians of the south ; viz., the ex- 
hibition day after day of drastic purgatives, — is very great ; whereas under 
the use of genfle laxatives occasionally, mild antiphlogistics, and the free but 
judicious use of the Peruvian bark or its preparations, the fatality is compa- 
ratively limited. Compared with the practice of a few years back, a system 
of treatment much more judicious and successful, is rapidly being adopted 
by the physicians of the south, and the number of those who would take 
pride in boasting of their hundred grain doses of calomel, or the number of 
drastic pills given in a dose, is small, indeed; and this too, notwithstanding 
the influence of professorial dicta, and college impressions. 

Until wi;hin the last few years, the Peruvian bark and its preparations 
were looked upon by almost all physicians as most inappropriate in all the 
phlegmasiae, and in all febrile diseases complicated with local inflammatory 
action, — and indeed they were considered inadmissible in any case of fever 
until the powers of the system were considerably exhausted, and the febrile 
excitement in a great measure subdued. They were looked upon only as 
stimulant and tonic ; and with these views, and to fulfil these indications only 
were they prescribed. 

I propose to give a few cases, exhibiting my own treatment, and nearly 
the method of treatment pursued by a few physicians of my acquaintance, 
illustrating the beneficial influence of quinine in such cases as I have alluded 



1844.] l&o\mg on Injlammatory Jlffedions of Malarious Districts. 89 

to. Some of the cases will be recognized as remittent fevers complicated 
with local affections, while others will be recognized as local inflammations 
on the consequent febrile excitement, of which a malarious influence is mani- 
fested by a periodical remittance. In all the cases it will be seen thatthough 
used as an important or principal remedy, yet it was not the only remedy ; 
and, it may be supposed that I attach undue importance to its influence. In 
reply, in the earlier periods of my practice, and sometimes recently in my 
own, but oftener of late in the practice of others, I have treated, and seen 
treated, such cases as I have described, without quinine ; and must say, that 
among them a much larger proportion of fatal cases have occurred ; and in 
the instances where recovery takes place, the disease was always more pro- 
tracted, and convalescence more doubtful and vacillating; and again, many 
times have I witnessed its almost ^^ talismanic^^ influence in the advanced 
periods of cases, which for a long time had resisted every variety of treat- 
ment that could be suggested, in the hands of the most skilful and expe- 
rienced physicians. 

As to the modus operandi of quinine, I have been able to form no very 
satisfactory opinion ; the observations of one day generally altering or modi- 
fying the opinions predicated upon the experience of a previous day. At 
one time I was disposed to look upon it as a sedative or contra-stimulant; 
and as a general rule, this is its most manifest effect ; and yet I have seen 
a very few cases in which it appeared to act as a stimulant. Its most general 
effect, however, is that of a sedative ; more certainly reducing and control- 
ling the action of the heart and arteries than any remedy with which I am 
acquainted. At another time I was disposed to think, that this controlling 
influence was only exerted in those labouring under the influence of malaria; 
but in the advanced stage of a case of endopericarditis, in which nothing in 
the circumstances of the patient, or the character of the accompanying fever, 
indicated a malarious taint, I was able, by administering, night and morn- 
ing, an enema containing grs. xx. of quinine, to moderate the rapid progress 
of the disease, and to reduce the pulse from 110 to 80, and to keep it at that 
standard, so long as the use of the quinine was persevered in. The influ- 
ence of the quinine was satisfactorily proved by the fact, that the omission 
of an enema was invariably followed during the next twelve hours, by a rise 
of the pulse to the original standard. One of the remedies used in this case, 
before the quinine, was digitalis, which had no eff'ect whatever in controlling 
the pulse. The case eventually proved fatal, in consequence of its becom- 
ing complicated with gastro-enteritis, induced by a moderate, but for the 
safety of the patient, too free a use of calomel and tartar-emetic. But to 
return ; it would not be considered scientific to call it a specific, and yet, in 
malarious diseases its effects seem almost antidotal. In almost every case, 
whatever the nature of the disease, supposing the system at the time to be 
labouring under the influence of malaria, either as the principal curative 

8* 



90 Boling on Inflammatory Affections of Malarious Districts. [July- 

agent, or as an important adjuvant, the best effects may be anticipated from 
its administration. 

This I have observed, under its use in the inflammatory affections of the 
chest, that an abatement in the physical signs almost invariably follows, very 
rarely precedes, an abatement in the febrile excitement; and a diminution in 
the action of the heart and arteries. Indeed, under its controlling influence 
over the sanguiferous system, the action of the heart may sometimes be re- 
duced from a state of high excitement, almost to a natural standard, long 
before any abatement takes place in the local inflammatory action as indicated 
by the physical signs. An improvement in the physical signs, however, 
generally follows in a short time after the influence of the medicine is mani- 
fested on the pulse. 

It sometimes happens, that, after the exhibition of quinine during a re- 
mission, for the purpose of preventing an expected exacerbation, a curious 
modification of the exacerbation will supervene. Thus, supposing that dur- 
ing the remission in which the quinine is administered, the patient's pulse is 
a hundred, and his situation upon the whole tolerably comfortable, the exa- 
cerbation may come on at the usual hour, with this difference, that the pulse 
remains unaffected, and rather sometimes diminished in frequency, and the 
temperature of the skin not greatly augmented, while the sensations of the 
patient are the same, or even more distressing than during any previous 
exacerbation. If the disease is an inflammatory affeciion of the chest, the 
exacerbation is manifested, together with the sensations of the patient, by 
the increased frequency of the respirations. The symptoms, and distressing 
sensations, indicating this modified exacerbation, usually subside at the usual 
time of the remission; and if the case has been one of simple remittent fever, 
generally no farther treatment is necessary ; the convalescence proceeding 
from this time, as if the exacerbation had been completely controlled. 
Should the case, however, have been complicated with inflammation of any 
organ, a continuance of the remedy for a few days, for the purpose of con- 
trolling the action of the heart and arteries, would be proper ; or a renewal of 
the febrile excitement, and of the inflammatory action would be the probable 
consequence. 

Case I. — Meningitis. — September 6th, 1838. Oakley, a negro child 
about three years old, had a slight attack of diarrhoea eight or ten days ago, 
and has had, for the last five or six days, considerable pain, which has in- 
creased every day since its development. Two days after the accession 
of fever, it was taken with severe convulsions, which it has had at inter- 
vals ever since. It has a slightly tumid abdomen, tongue foul, rather dry, 
and red at the edges ; and considerable thirst, nausea, and vomiting. Pulse 
180, hard but small ; left arm spasmodically flexed upon the humerus, 
and the wrist and fingers upon the forearm ; while at the same time the hand 
is permanently supinated, by a rotation of the radial side of the hand under, 
being a continuation of the usual movement of pronation. There is at times 
strabismus; the left eye being turned outwards; the right, inwards. There 



1844.] Boling on Inflammatory Affections of Malarious Districts. 91 

is a constant rolling of the head from side to side ; a low plaintive moaning 
without tears ; and a frequent application of the right hand to the head. 
There is great heat of the surface; more particularly of the head, and vio- 
lent throbbing of the temporal arteries. In the early part of its sickness, it 
took a dose of castor oil ; since the operation of which, its bowels have been 
costive. I)t. — Hydrarg. c. creta grs. v. immediately. Its head to be shaved, 
and frequently sponged with cold water ; occasionally the cold douche ; sina- 
pisms to abdomen and lower extremities. Evening. — Pulse 150. There is 
an aggravation of all the symptoms; and I now learn, that ever since the 
attack, from three o'clock in the evening, till one o'clock in the morning, this 
has been the case. Continue cold applications to head ; apply a blister to 
its neck, and give it 5ij of castor oil ; to be followed by enemata, occasion- 
ally, till its bowels are freely evacuated. 7th. It had last night a severe con- 
vulsion ; has had several green slimy evacuations. Pulse 128 ; blister has 
drawn well. R. — Quin. sulph. gr. viii. Syrup, limonis ^i. M: — a tea-spoonful 
every hour. Evening. — Pulse 140. Strabismus, which was scarcely percep- 
tible in the morning, is now more manifest, though not as bad as it was yes- 
terday morning. Omit the quinine ; repeat hydrarg. c. creta gr. v. 8th. Has 
had severe operations of the same character ; pulse 116; tongue a little moist; 
strabismus scarcely perceptible ; and spasm of left arm considerably dimi- 
nished. B. — Quin, sulph. gr. viii. syrup rhei arom. ^i. ; a tea-spoonful 
every hour. Evening. — It is much the same, but apparently less thirsty. 
Continue quinine, one grain every third hour ; repeat hydrarg. c. creta gr. 
V. 9th. In every respect, apparently very much improved. Pulse 107 ; 
eyes straight, and spasm of left arm almost entirely relaxed. Has taken 
a litde boiled milk ; the first thing it has swallowed willingly since its sick- 
ness except water. The quinine was continued a few days longer ; one 
grain every fourth hour; and a gradual improvement took place, till the 
establishment of complete convalescence. 

Case II. — Disease of the brain — convulsions, ^^c, occurring in connec- 
tion with remittent fever, — Oct. 14th, 1843, I visited an overseer, about 
eight miles from town; and after prescribing for him, was asked to examine 
and prescribe for his child, a little girl about six months old. She was taken 
sick about two weeks ago, with, from what I could learn, a pretty severe 
attack of remittent fever. About the third day of the fever, she was taken 
with convulsions, of \vhich in the course of a few days she had some three 
or four paroxysms. During the fits, the extremities of the right side were 
more convulsed than those of the left ; and they are now paralyzed. The 
power of motion of the left side is unaffected. Its body has a pale waxen 
appearance, there being an uniformity of colour over the whole surface; 
there is present a peculiar glossiness of the cheeks, and a plumpness asto- 
nishing after so long and so severe a sickness. The eyes have a dull inex- 
pressive appearance, and the pupils are very much contracted; tongue dry 
and covered with a white coat; it has considerable thirst, and at times vomits 
a green watery fluid ; bowels have been rather loose than otherwise, the evacu- 
ations being green, thin, and slimy; spleen enlarged; abdomen tumid; pulse 
160, small and jerking; surface hot, more particularly about the head and 
face ; a very loud bellows murmur is heard by applying the stethoscope to 
the anterior fontanel. I directed two grains of calomel to be given immedi- 
ately, and one grain of quinine every second hour, till eight grains in all 
should be taken ; a blister to the back of the neck ; head to be frequently 
sponged with cold water; warm pediluvia and sinapisms to the extremities. 



92 Boling on Inflammatory Affections of Malarious Districts, [July 

Oct. I5th. The child is very much improved; its tongue is moist; the 
temperature of its body diminished, and its pulse is only 130, and fuller and 
softer. The paralysis continues unimproved, and the appearance of the eyes 
is the same; the cephalic bellows murmur has diminished in loudness, about 
in proportion to the diminution in the jerking character of the pulse. It has 
had three green slimy evacuations ; in place of the dry, polished feel of the 
skin it is moist and pleasant. R. Quin. sulph., gr. viii. — D. in pulv. iv; one 
to be taken every sixth hour. 

I6th. h has scarcely any fever; pulse 110; skin cool and moist; tongue 
clean and moist; eyes have a better appearance; the paralysis remains undi- 
minished; it takes the breast with avidity. Be. Quin. yulph., gr. i, every 
fourth hour. I did not visit it again, but learned from its father, three weeks 
after my last visit, that it continued to get belter from that time. It had not, 
however, entirely regained the use of the paralyzed side, though it had im- 
proved, and was still continuing to improve. 

Case III. — Acute Bronchitis — Remittent Fever. ' On the night of July 
7th, 1841, I was called to see George Philpot, a little boy two years and a 
half old, who, the messenger said, had the croup. He had been feverish, 
and had had a slight cough for several nights. The present exacerbation of 
fever came on at 4 o'clock this evening, and is now very high; pulse 160, 
and moderately full ; skin hot; thirst very great; face flushed; cough inces- 
sant; respirations 60, and great difficulty of breathing; a loud sonorous rale 
is heard in every part of the chest. I took about two ounces of blood from 
his arm, applied a mustard-plaster to his chest, and prescribed, of calomel 
and ipecac, each, gr. ii, immediately, and the ipecac, to be continued in 
half grain doses every hour, or to be regulated so as to keep up a continual 
nausea with occasional vomiting; I likewise directed an enema to be ad- 
ministered in about two hours after the first dose. 

July St h. Has had two evacuations from his bowels, and has vomited 
some five or six times through the night ; he is in every respect much im- 
proved; pulse 140; respirations 38; skin and tongue a little moist: the dry 
sonorous rale is changed to a coarse moist mucous rale, scattered here and 
there over all parts of the chest; cough loose and less frequent. Continue 
the ipecac. Evening. — He is much the same, but has a little more heat of 
skin. Continue the ipecac, but less frequently. At 10 o'clock at night I 
was again called to him. His fever has increased rapidly since I saw him; 
pulse 170 ; respirations from 68 to 70, and very laborious ; sonorous and 
sibilant rales heard in all parts of chest. A strong mustard plaster to be 
applied to chest; his feet to be kept immersed in warm water for some time, 
and then to be rubbed with mustard; ipecac, gr. i, to be given every half 
liour till free vomiting takes place, after which it is to be continued in suffi- 
cient doses to keep up constant nausea. 

9th. Skin moist; pulse soft, 144; respirations 40; mucous rale again has 
taken place of the dry sonorous and sibilant rales ; thirst diminished, and 
tongue less dry. R. Quin. sulph., gr. xii; sacch. alb. gr. xx. — M. and D. 
in chart, viii ; one to be given every hour. Evening. — He is in a free per- 
spiration ; his pulse 120; respiration 32; cough loose, and apparently causes 
no pain; cheerful, and has been sitting up in bed. R. Quin. sulph., gr. viii; 
sacch. alb. gr. xvi. — M. and D. in chart, viii; one to be given every third 
hour. 

lOth. Pulse 102; respiration easy; expectoration free ; skin moist. Con- 



1844.] Boling on Inflammatory Affections of Malarious Districts. 93 

tinue same. Evening. — Pulse 96. He rapidly recovered under a continu- 
ation, for a short time longer, of the quinine. 

Case IV. — Pneumonia, Sfc. — July 7th, 1843. I was called to see 



Coffey, a negro girl, four years and a half old. She was taken on the even- 
ing of the 5th with fever, attended with considerable cough. In the course 
of the night her fever abated, and she was up and playful on the 6th, till 5 
o'clock in the afternoon, having, however, slight fever all day. At this time 
her fever rose with great violence, accompanied by an incessant cough. 
During the night she took a sufficient quantity of ipecac, at intervals, to pro- 
duce emesis. Present state, (which they say is a considerable improvement 
on what her condition was through the night,) pulse 140, very weak ; respi- 
rations 106; cough incessant; no expectoration; body and head hot; ex- 
tremities cool ; tongue dry, edges red, and dorsum covered with a smooth 
white coat. Slight dulness on percussion just below inferior angle of left 
scapula, and around this part the crepitant rale is heard. Over all the other 
parts of the chest, dry, sonorous, and sibilant rales are heard, with here and 
there a slight crepitant rale, sufficient in all parts completely to prevent a 
pure respiratory murmur from being heard. R. Pulv. ipecac, gr. i, every ten 
minutes, till free emesis takes place. (Bad as her condition is at present, it is 
undoubtedly the early part of a remission, and at 4 or 5 o'clock in the even- 
ing an exacerbation will take place, which in all probability, if left uncon- 
trolled or unmodified by treatment, will prove fatal). K. Quin. sulph., gr. xii — 
D. in pulv. iii, one every third hour, so that the last one may be taken at 3 
o'clock; sinapisms to extremities. Evening. — Pulse 135 and fuller; respira- 
tions 90; auscultatory signs the same, with the difference that the rales do 
not altogether prevent the respiratory murmur from being heard in parts of 
the chest; sweating freely about the head ; temperature of the surface more 
equable; tongue a little moist. R. Hydrarg. sub. mur., gr. v, immediately; 
and gr. i. of ipecac, every hour through the night. 

July 8th. Pulse 120; respirations 70; tongue rather more dry than it was 
last night; auscultation the same; has had two operations, and vomited once 
in the night. R. Quin. sulph. pulv. ipecac, aa gr. xii ; ant. potass, tart. gr. i ; 
mucilage acaciae, 5ij. — M., take a teaspoonful every hour. Evening. — 
Pulse 130; respirations 80 when asleep, but when awake and after the least 
exertion, 110 ; dilatation of alae nasi at each inspiration. Continue the mix- 
ture, but increase the quantity of quinine in it to xxiv grs. 

9th. Pulse 112; respirations 44; respiratory murmur heard all over chest, 
somewhat obscured by a scattered sonorous rale, more especially on leftside 
postero-inferiorly. She retains the medicine well. Evening. — Pulse 120; 
respirations 48 ; she has had three or four thin bilious evacuations. Con- 
tinue the mixture every second hour. 

loth. Pulse 114; respirations 40 ; a scattered sonorous rale heard only 
here and there. K. Pulv. ipecac, gr. viii ; ant. potass, tart., gr. ss; mucilage 
acaciae ^'\, a teaspoonful every second hour. Evening.— The same. 

llfh. Pulse and respirations the same ; bowels have been very open, and 
the discharges thin and watery; skin cooler than it has been; she seems a 
good deal prostrated ; tongue fiery at the edges, and covered on the dorsum 
with a thick brown coat. R. Mist, creta,, ^i ; Tr. opii camph., 5ij. — M., a 
teaspoonful every second hour; mucilaginous drinks. Evening. — Pulse 
120; respirations 36; cough has almost entirely ceased ; no physical signs 
of disease of the lungs or bronchia ; tongue very dry; thirst very great; dis- 
gust for food; tunica sclerotica very yellow; has vomited frequently 
through the day, and has had several thin, watery evacuations. Continue 



94 'QoXmg on Injlammatory *Sffections of Malarious Districts, [July 

the mixture and mucilaginous drinks. Sinapism to abdomen, to be followed 
by a large moist poultice. 

12/A. Purging and vomiting have ceased; in other respects she is much 
the same. Continue mucilaginous drinks. 

13/A. Tongue a litde moist; in other respects she is much the same. 
From this time the improvement was regular, but tedious. The tongue 
gradually became clean and moist; the evacuations from the bowels more 
natural, and a gradual return of the appetite took place, all indicating a pro- 
gressive improvement in the state of the stomach and bowels. By the 18th, 
she was almost entirely clear of fever, and had some little desire for food; 
but she was not considered safe till about the 24th. 

In this case an occurrence took place which is by no means unusual with 
us here, in the treatment of acute thoracic diseases, particularly when tartar 
emetic or calomel is used to any extent, and more especially when they are 
used in combination, viz., the supervention of gastro-enteritis, about the time 
or soon after a considerable amendment has taken place in the original dis- 
ease. Sometimes, indeed, the secondary disease, and that very rapidly too, 
proving fatal after all evidences of disease of the lungs have disappeared. 
Of that character is the following case. 

Case V. — Pneumonia succeeded by congestive gastro-enteritis, ^^c. — Jan. 
4th, 1843. Was called to see Frank Reynolds, a stout young man, twenty 
years old. Yesterday morning about 11 o'clock, (having felt a little unwell, 
and had a slight cough and pain in the right side for several days,) he was taken 
with a slight chill succeeded by some fever, and a rather severe cough and 
acute pain in right side. This morning, about 10 o'clock, he had another 
slight chill, and about 12, one much more severe. Now, (2 o'clock,) cough 
constant; expectoration scanty; pain in right side very severe; headache; 
thirst; skin hot and dry; tongue white and rather dry on dorsum; pulse 
120, full and hard ; respirations 40 ; dulness on percussion over lower part 
of right lung, and a little higher up, a coarse, crepitating rale. V. S. to xx 
oz.; calomel, gr. xv, to be taken immediately, and to be followed in two 
hours by an enema ; after the operation of which, he is to commence taking, 
every second hour, a tablespoonful of the following mixture. R. Ant. potas- 
sae tart., gr. iv; Tr. opii. gtt. xxxii ; mucilage acacias, §iv — M. Evening. — 
His fever has abated ; he has vomited a little once, and has had three evacua- 
tions from his bowels; expectorates with tolerable freedom a tenacious, 
transparent, yellowish mucus, mixed at times with a small quantity of a 
dark brown matter. Blood which was taken in the morning, is covered 
with a thick and tough huffy coat. Continue the mixture every fourth hour, 
but double the dose, and in addition: li. Quin. sulph., gr. xxiv, divide in 
parts three, one to be taken at midnight, one at four, and the other at eight 
o'clock in the morning. 

bth. Pulse 108 ; respirations 30; pain less severe, and cough less trouble- 
some; expectoration the same; tongue moist; no vomiting. Continue the 
antimonial mixture. Evening. — At 11 o'clock, his fever commenced rising, 
without being preceded by a chill; pulse 116; respirations 38; skin hot 
and dry; thirst increased; no vomiting, and very little nausea. R. Quin. 
sulph., gr. xxxii; antimon. potassae tart., gr. ii; ext. glycyrrhiz. syrup simp. 



1844.] Boling on Inflammatory Jiffedions of Malarious Districts, 95 

aa q. s. Ft. mass, in pil. viii, D.; one every second hour. V. S. to xii 
oz.; calomel, gr. x, immediately. 

Qth. Pulse 100; respirations 30; cough less troublesome ; expectoration 
easy, and of the same character; skin and tongue moist; three bilious evacu- 
ations; no vomiting, and but slight nausea ; very little thirst; dulness dimi- 
nished. Evening. — As he was in the morning. Continue the same. 

1th. Very much improved; pulse 80; respirations 24; slight crepitant 
rale; no dulness ; perspiring freely; tongue moist and relaxed. Continue 
the pills every third hour. Evening. — The same. 

Sth. A slight improvement on yesterday; no pain in side; no dulness, 
and crepitant rale heard over a very small space. Pulse 78, and full and soft ; 
skin moist and cool; tongue moist; no thirst; some little desire for food; 
cough very trilling. Omit the quinine. R. Ant. potassae tart., gr. ii; Tr. 
opii, gtt. xvi ; aquse pur., 5iv.— M., a tablespoonful every second hour. 
Evening. — Still doing well. Continue the mixture. 

9th. He is much worse. About midnight the perspiration ceased, and bis 
skin gradually became hot and dry; he became restless and uncomfortable, 
but complained of no definite pain; vomited once, and had several thin, 
serous evacuations. His tongue is at this time dry, and fiery at the edges ; 
abdomen tympanitic, (up to this time it has been soft and relaxed ;) great 
thirst; nausea; restlessness and anxiety; skin and eyes yellow. Pulse 128, 
small and soft; no dulness; no rale; no cough. R. Hydrarg. subm., gr. x; 
pulv. opii, gr. ii. — M. &l D. in chart, iv, one to be taken every third hour. 
Blister to abdomen ; mucilaginous drinks. Noon.— All the symptoms aggra- 
vated ; great nausea ; restlessness and thirst; skin and eyes intensely yellow; 
tongue parched, brown, and cracked; teeth covered with a black sordes ; 
delirium. Pulse 140, small and weak; extremities clammy. Continue the 
powders, with the addition of a grain of camphor, and a grain of cayenne 
pepper to each. Sinapisms to extremities. Evening.— In addition to an 
aggravation of all the previous symptoms, he is vomiting up large quantities 
of a black matter, having much the appearance of pulverized extract of 
liquorice dissolved in a thin mucilage of slippery elm. Dr. Holt now saw 
him with me ; he died about dark ; no post-mortem examination. 

Case VI. — Bronchitis. Violet, a negro woman, about 45 years old, 
was taken with a high fever and cough on the 24th of August, 1843. Up to 
the time I was called to see her (Aug. 31st) she grew worse every day, and 
for a short time back has appeared a good deal worse at night. Her master 
says that he thought she would have suffocated from accumulation of mucus 
in the bronchi last night, and that her pulse was so frequent he could not 
count it. Pulse now 120; respirations 44; tongue moist, broad, and relaxed, 
and coated with a white fur; skin hot and dry; acute pain in right side, and 
all along the course of the junction of the diaphragm with the ribs. This 
latter she attributes to the violence of her cough; expectorated with difficulty 
a good deal of tough frothy mucus tinged with blood; mucous rale heard in 
almost every part of the chest, with here and there a loud sonorous rale. 
She has taken a dose of calomel and one of oil, which operated freely on 
her. B. Quin. 3ulph.,gr. xxxvi; extract, cinchona?, gr. ix. — M. fiat pilul. 
ix, two of them to be taken immediately, two in two hours, and one every 
second hour after. Should there be extreme danger of suffocation to-night 
from accumulation of mucus, she is to take an emetic of sulphate of zinc 
and ipecac. 

September 1st. Pulse 116; respiration 34; skin cool and moist; cough 



96 Boling on Inflammatory Affections of Malarious Districts. [July 

almost as bad as yesterday; stethoscopic signs the same; last night's exacer- 
bation was not near so bad as the one of the previous night; for the last two 
nights she has scarcely slept any. R. Quin. sulph., gr. xxiv; extract 
cinchonae, gr. vi. — M. fiat pilulas vi, one of them to be taken every third 
hour; and R. Pulv. ipecac, et opii, hydrarg. c. creta, aa gr. xv. — M.; to be 
taken to-night before bed time. 

2d. Through mistake only three of the pills were taken yesterday. Last 
night she was thought to be dying, but recovered after the administration of 
the powder and some brandy toddy. Pulse this morning 120, but increases 
to 140 on the least exertion; respirations 40, and very laborious; she can 
only breathe now with any degree of comfort in a semi-recumbent posture; 
tongue rather dry, with a brown streak on the dorsum; gums a little sore; 
auscultation the same, with here and there a fine sibilant rale. R. Quin. 
sulph., gr. xxxvi; extract, cinchonas, gr. xii. — M. fiant pilulae, xii; two of 
them to be taken every four hours. Evening. — Pulse 120; respirations 30; 
other symptoms as in the morning. Continue the pills, and repeat the 
powder of hydrarg. c. creta and Dover's powder. 

3f/. Pulse 104; respirations 28, and less laborious; expectorates more 
freely. Continue the pills. Evening.— Again the pills have not been ad- 
ministered regularly, owing to the obstinacy of the patient. Pulse 120; 
respiration 36. Continue the pills, which she has promised to take as 
directed ; repeat the powder. 

4:tli. Pulse 112; respirations 28 ; had two dark consistent evacuations last 
night. Continue the pills. Evening. — To-day about noon she was taken with 
griping pains in her bowels, followed by five or six thin dark evacuations in 
quick succession, (the effect, no doubt of the hydrarg. c. creta,) and as she 
appeared to be sinking very fast under their influence the pills were sus- 
pended, as the operations were attributed to them. She took thirty drops of 
laudanum to arrest the discharges. Pulse 128, and very much quickened on 
the least exertion; respirations 36; tongue brown, dry, and cracked; great 
thirst: stethoscopic signs the same; cough very frequent; expectoration 
scanty, and streaked with blood. She is able, however, to rest more in the 
recumbent posture. R. Quin. sulph., gr. v; ext. cinchonas, gr. ii, every 
fourth hour; mucilaginous drinks; Tr. opii, gtt. x, after each operation. 

^th. In spite of the free administration of laudanum she had five or six 
large thin dark evacuations last night; tongue, cough, expectoration, and 
stethoscopic signs the same. She is very weak, and had to take brandy 
toddy occasionally through the night. Pulse 120; respirations 30. R. 
Quin. sulph., gr. vii; extract, cinchonae, gr. xxiv; acid sulphuric, gtt. xx; 
aquae purae, ^iii. — M.; a lablespoonful to be taken every third hour; repeat 
Tr. opii pro re nata. Evening. — Pulse 116; respiration 38; perspiring 
freely on head and face; has had three frothy evacuations somewhat resem- 
bling yeast. Continue the same. 

&;h. Pulse 108; respirations 20; one operation last night. Evening. — 
Pulse and respiration the same; expectorates with more ease; tongue moist. 
Continue the mixture every fourth hour. 

T//?'. Pulse 106; respiration 22; says she feels much better. Continue 
the same. 

8/^. Pulse 100; respirations 20, free and easy; skin cool and moist; 
cough less troublesome; expectorates freely an opaque yellowish mucus 
without any blood ; a coarse moist mucus rale only heard here and there 
over chest. Continue the mixture. 

9th. Pulse 80; respirations 20; tongue clean and moist; and in fact in 
every respect she is much better. Continue the quinine mixture every sixth 



1844. J Boling on Inflammatory Affections of Malarious Districts. 97 

hour, and occasionally a teaspoonful of the following mixture. R, 01. tere- 
binth., §ss; Tr. opii, Tr. lobeiiae, aa^ij; mucilage acaciae, ^iiiss. — M. Under 
a continuation of this treatment she was convalescent in a short time, but 
continued quite weak for a good while. It will be observed that on the 
several occasions on which the quinine was partly omitted, an aggravation of 
all the symptoms occurred. 

Case Yll.— Dysentery . September 3d, 1843, David H. Carter, 28 years 
old, says that for several days he has felt unwell, and that on the night of the 
1st he was taken with diarrhoea, which gradually became more painful and 
troublesome, till at length it has terminated in severe dysentery. Since early 
last night his stools have been small, frequent, slimy, and bloody, and accom- 
panied with severe griping pains, and a sensation of coldness in the bowels. 
In addition to the pains already alluded to he complains of a fixed and deep- 
seated pain in the epigastrium. He has slight nausea and vomiting; pulse 
free and moderately firm; heat of skin very little above the natural standard; 
considerable thirst; tongue foul and red at the edges. R. Massa hydrarg., 
gr. XX ; pulv. opii, gr. ii. — M. and D. in pil. iv; one to be taken every fourth 
hour; gum-water to be his only drink. Evening. — Has less pain, and has 
had but one operation since morning. 

4//i. Is much as he was yesterday morning; had several operations in the 
night composed of bloody mucus, and attended with considerable griping; 
complains of headache. 

^th. Has taken no medicine since yesterday noon ; had several operations, 
with a good deal of straining and griping in his bowels, last night; pulse 
full and firm. V. S. to twelve ounces; repeat pills every sixth hour. 
Evening. — Says he feels better. Repeat pills every eighth hour. 

6/A. Four operations of the same character last night; considerable ten- 
derness of abdomen. Continue pills. My attention was now directed to 
the fact that the operations from his bowels were more numerous at night; 
and that he has always in the morning complained more of pain through the 
night than he has in the evening of pain through the day. By questioning 
him closely I discovered that he had, every night, considerably more fever 
than in the day, indicated by increased thirst, headache, abdominal pains, 
&c., and that every night about 9 o'clock the operations from his bowels 
commenced. At 10 o'clock at night I visited him, and found him suffering 
much from severe griping pains, headache, thirst, &c.; skin hot and dry; 
pulse 100, full, and rather hard; tongue dry and brown on dorsum; he has, 
since 9 o'clock, had two evacuations, composed of a bloody mucus floating 
in a thin blackish fluid. B. Mist, creta, ^iss ; Tr. opii camphorat., ^ss. — M.; 
a tablespoonful after each operation; V. S. to sixteen ounces; a sinapism to 
abdomen ; to be followed by a large mush poultice, and to be renewed three 
times a day. 

1th. Had one operation after I saw him last night. He is much as he 
was yesterday morning; pulse 80; slight thirst; tongue less dry than it was 
last night. R. Quin. sulph., gr. xxiv; pulv. opii, gr. j ; extract, taraxaci, 
gr. viii. — M. fiant pilulse viii ; two of them to be taken every third hour. 
Evening. — Has taken all the pills; repeat them; one every third hour 
through the night; chalk mixture, pro re nat. 

8^A. Says that he rested better, and has had much less pain, thirst, &c., 
through the night than usual. Had one operation, composed of a dark 
watery fluid, with a little bloody mucus suspended in it; had no fever, and 
perspired freely all night. Repeat the quinine and opium pills. 
No. XV.— July, 1844. 9 



98 'Bo\mg on Injlaramatory Affections of Malarious Districts, [July 

Qth. No evacuations from his bowels last night; he has neither thirst nor 
heat of skin, but yet he does not feel as comfortable as he did yesterday 
morning, owing, he says, to a sensation of fulness above the pubes, and a 
sharp pain which frequently darts across the abdomen in the direction of the 
transverse arch of the colon. K. 01. ricini, §i; ol. tereb., gi; pulv. acaciae, 
5ij ; sacch. alba, ^ss; aqua cinam., ^iii. — M.; half to be taken immediately, 
and the other half at the end of three hours if the first does not operate in 
that time. Noon. — He had a large thin yellow evacuation from his bowels 
before the mixture could be procured, after which he felt much relieved, and 
consequei^tly did not take it. R. Quin. sulph., gr. xxiv; extract, tarax., gr. 
viii. — M., fiant pilul. viii; two of them to be taken every second hour. 

IQth. Much better; pulse 70; skin cool and moist; tongue moist; no 
thirst; no evacuations from bowels, and very little pain; some desire for 
food. Continue the quinine pills, one every third hour. Evening. — Pulse 
62, soft and full; in every respect he is much improved. 

On the 12th he had a slight relapse from imprudence in his diet. For 
several days he had at times some griping, and his evacuations contained a 
little bloody mucus; the nightly exacerbations, however, returned no more. 
He took during this time a grain of calomel and half a grain of opium twice 
a day, and continued likewise the quinine pills, one every third hour, under 
the use of which his pulse was kept to from 64 to 70, full and soft, and his 
skin moist. From the time he was taken sick to the 10th he ate nothing, 
using only gum-water for his drink, consequently he was a good deal debili- 
tated. He took no medicine after the 15th, and on the 18th I ceased to 
visit him. 

Case VHI. — .Jackson, a young gentleman, 24 years old, was attacked on 
the 21st Oct. 1840, severely with dysentery, attended with high febrile 
excitement. Up to the 28th, the time I was first called to see him, he has 
been principally treated with mercurials, of which he had taken, he said, 
very freely. He had also been bled once, and blistered over the abdomen. 

Present state, (9 o'clock, A. M., 28th). Skin hot and dry; tongue red at 
edges, parched, and covered on the dorsum with a thick brown coat; teeth 
dry; gums swollen; several small ulcers on the insides of his cheeks, the 
effect, no doubt, of the mercurials; distressing nausea, and vomiting fre- 
quently of a grass-green fluid; as often as every fifteen or twenty minutes 
he has a small bloody mucous operation, attended with the most excruciating 
griping and tenesmus; thirst intense; pulse 130, small and hard. Says he 
has taken, with scarcely any alleviation, several large opium pills. R. Mag- 
nes. sulph., ^i; magnes. calc, 3i ; aqua cinam., ^ viii. — M.; a wine-glassful 
to be taken every hour till an alteration in the character of the stools indi- 
cates its action on the bowels. He vomited several times while taking it; 
nevertheless the fourth dose was succeeded by several thin bilious evacua- 
tions containing very little blood and mucus, and passed with much less pain. 
After this he was comparatively easy till about 10 o'clock at night, when his 
pulse rose, the heat of skin, thirst, nausea and vomiting, &:c. increased, and 
the evacuations became as frequent as ever, mucous and bloody, and attended 
with the same distressing pains; he was likewise slightly delirious. During 
the night he took one or two small portions of morphine; had a warm poul- 
tice kept constantly on his abdomen, and was allowed only gum-water in 
small quantities to drink. 

29//?. A little abatement in the symptoms; pulse 130; skin not so hot, 
and thirst, nausea and vomiting somewhat diminished; operations of the 



1844.] Boling on Inflammatory Affections of Malarious Districts. 99 

same character, but less frequent, not oftener than once every three quarters 
of an hour. I now suspected that he had exacerbations, coming on late in 
the evening and continuing through tlie night, and by a close investigation 
discovered that this had been the case from the beginning. R. Quin. sulph., 
gr. xxiv; morph. sulph., gr. i; mucilage acaciae, q. v.; — fiant pilul. vi; one 
of them to be taken every second hour; sinapisms to extremities; continue 
gum-water and poultices to abdomen. I now left him with the promise to 
see him again at night. Evening. — After taking a couple of the pills, and 
throwing one of them up, his nausea became so great that he could not be 
prevailed on to take any more. His fever is again on the increase. 

30/A. He passed, if any thing, a worse night than the last, the treatment 
pursued being much the same; a slight abatement in the symptoms this 
morning. In hopes that it would enable him to retain the quinine on his 
stomach, I gave him, at one dose, a half a grain of morphine, and when fully 
under its influence directed a four grain quinine pill to be given every second 
hour. Evening. — The morphine had the effect of moderating the nausea 
in a slight degree, but he retained only two of the pills ; he has slept some, 
and has had fewer operations; he is, in other respects, much as he was yes- 
terday. 

31s^. He passed last night very much as he did the night before, with 
incessant nausea and vomiting of a greenish flocculent matter, suspended in 
a glairy fluid; pulse 148, small and corded; tongue black, parched and 
cracked; operations, composed of a bloody mucus suspended in a reddish 
fluid, every 20 or 30 minutes; skin hot and dry; great prostration; teeth 
dry and covered with a black sordes; as is usual in the morning, a slight 
abatement in the severity of the symptoms has taken place. I now deter- 
mined to administer the quinine by the rectum, and to prepare him to retain 
it, gave him an enema composed of Tr. opii, 3i; starch, ^ij. It was rejected 
in a few minutes. I immediately repeated it, and this one was retained a 
couple of hours; I now administered gr. xxx of quinine; gtt. xx of lauda- 
num in §ii of starch; this, at the end of two hours, he still retained. I now 
left him, directing the enemata to be continued, one every third hour, and the 
quantity of laudanum varied according to the effect. Evening. — He retained 
the two first enemata until nearly time to administer the third; the third and 
fourth each he retained about two hours, discharging with them a small 
quantity of bloody mucus; he has slept soundly, and has been perspiring 
some this afternoon; pulse 128, fuller and softer; thirst, nausea and vomit- 
ing somewhat diminished. Continue the enemata with forty drops of lauda- 
num in each. 

November 1st. As heretofore, an exacerbation occurred last night, but 
much less severe than the previous one, his pulse at no time rising over 135; 
the enemata were not well retained, and he had some six or seven operations, 
tl gave him another enetna containing ^i of laudanum, and directed the 
quinine enemata to be continued as yesterday. Evening. — Pulse 116, full 
and soft; skin moist; thirst diminished; has had but three evacuations. 
Continue the enemata. 

2d. Is much as he was yesterday evening; did not retain any of the ene- 
mata more than an hour. R. Morph. sulph., gr. i, immediately; continue 
the enemata. Evening. — Pulse 100, full and soft; tongue moist, and a free 
discharge of saliva has taken place; perspiring freely; has had several 
evacuations composed partly of a dark-consistent bilious matter. Continue 
the enemata every fourth hour. 

3(1. Pulse 96; skin moist, and tongue moist and nearly clean; scarcely 

\ 



100 Boling on Inflammatory Affections of Malarious Districts. [July 

any thirst ; two evacuations through the night v/ith very little pain. Con- 
tinue the enemata. Evening. — Tulse 84; no thirst; neither desire nor dis- 
gust for food. Continue enemata every sixth hour. This was continued a 
day or two longer. His appetite soon returned, and his recovery was rapid. 
He has complained of deafness since the enemata were commenced. 

Case IX. — Metrorrhagia — Inflammatory Engorgement of Cervix Uteri. 
December 3d, 1843, I was called to see Betsy, a negro woman 35 years old, 
from whom, about six months ago, a fleshy mass, either a mole or an uterine 
polypus, as large as a turkey's egg, had been expelled after several days of 
severe pain, attended with flooding. For the last two days she has had 
violent pains, resembling colic, in the lower part of her abdomen. Her 
catamenia have been regular for the last four months, and a few days ago 
she had them in the usual quantity, and without pain; she has no fever. 

I prescribed a dose of castor oil and the warm bath, the operation of the 
oil to be followed by a full opiate, and left her, believing that she would 
require no farther attention. On the 9th I was again called to see her, and 
learned that after the operation of the oil, and the administration of the 
opiate, she was considerably relieved; but that the next evening the pains 
began to increase, and gradually became again very severe, attended likewise 
with a pain in the back, and a fixed pain just above the pubes. On the 6th 
she was taken with uterine hemorrhage, which has continued on her, rather 
profusely, up to the present time. She is a good deal weakened from loss 
of bloody pulse a little quickened; some thirst, and increase of heat of skin; 
and she complains of scalding and difficulty in urinating. I prescribed sugar 
of lead and opium in full doses; quiet, in the recumbent posture, with the 
hips a litde elevated; low diet, cooling drinks, &c., which were persevered 
in to the 12th, with very little alleviation of pain, and no abatement in the 
haemorrhage. She is now (12th) quite feverish, and more prostrated. Ques- 
tioning her relative to the matter, she informed me that always at night she 
felt thirsty and more feverish, and that the pain and haemorrhage w^ere much 
more severe than through the day. 

Examination per vaginam. — Mucous membrane of vagina hot and swol- 
len; cervix uteri of the natural length, but enlarged to treble the natural* 
size; hard, hot and exquisitely sensitive. R. Quin. sulph. Biiss; extract, 
hyoscyami, gr. viii; aquae, ^'n. — M. A teaspoonful to be taken every two 
hours, and continued until one half of it is taken; to be commenced with 
early to-morrow morning; the other half to be taken the same way the next 
day; warm bath and sinapisms to back and lower part of abdomen to-night. 
I was unable to see her again till the 19th, when I found her convalescent, 
and learned that on ihe 18th she continued to have some pain and haemor- 
rhage, but rested much better at night; about noon on the 14th the haemor- 
rhage ceased, and has not returned since. She continued to have slight 
pains in the pelvic region for a day or two longer. She says she is now 
entirely well, with the exception of weakness. 

Case X. — Acute Inflammation of Neck of Bladder — Incontinence of 
Urine, 8fC. On the night of October 6th, 1843, I was called to see Mrs. 

, a lady recently married, 18 years old, and six months advanced in 

pregnancy. On the 4th she had a slight chill; she has been feverish for 
several days. This evening she was taken with most excruciating pains in 
the neck of the bladder and urethra, after the continuance of which, for a 
couple of hours, she became unable to retain her urine. It is now dribbling 



1844.] Boling on Inflammatory Affections of Malarious Districts. 101 

from her guttalim; she complains of violent pains in and about the neck of 
the bladder, and scalding and soreness of the vulva; pulse 96, full and hard; 
headache; thirst, and increased heat of skin. She likewise complains of a 
deep-seated pain just above the pubes, from which she has suffered more or 
less ever since a febrile attack which she had three or four months ago, 
attended with an "affection of the bladder." 

Her urine, after standing some time, deposits a white pulverulent matter, 
mixed with, or suspended in a stringy mucus. R. Massa hydrarg. gr. x; 
morph. sulph. gr. ss. — M. fiant pilulas, ii. One of them to be taken imme- 
diately, and the otiier at the end of three hours, if in that time she is not more 
comfortable. V. S. to xii oz; warm bath. 

October 1th. Pulse 78, softer; skin cooler; she is more comfortable, and 
can retain her urine, and has less pain and burning in neck of bladder and 
vulva; bowels costive, B. Massa hydrarg. gr. x; extract, colocynth. c. 
gr. XV. — M. fiat massa. in pilulos v dividendo, to be taken immediately. 
Evening. — Pulse 90, full and hard; skin hot and dry; thirst; no evacuation. 
She is again unable to retain her urine, and is in as much pain as she was 
last night. Repeat the warm bath and morphine; to be followed towards 
morning by a saline cathartic. 

Sth. Pulse 80; she is much as she was yesterday morning; has had tw© 
operations. U. Quin. sulph., gr. xxiv; extract, tarax., gr. vii. — M. ft. 
massa in pilulos, viii dividendo, two of them to be taken every two hours. 
Evening. — Pulse the same; no thirst; retains her urine, and has no pain 
scarcely, except above the pubes ; some roaring in her ears. After this she 
had no return of the incontinence of urine, and the pain in the neck of 
bladder and urethra, and the soreness of the vulva gradually subsided under 
a continuation of the quinine. 

In a few days after this she was taken with a mild attack of leucorrhcea, 
which yielded to a small quantity of copaiba and weak injections of sulphate 
of zinc. The pain above the pubes was improving, and the urinary deposit 
diminishing, when I last saw her, — a month after the attack, — under a mild 
mercurial course, and the use of an infusion of diosma, juniper berries, and 
uva ursi. 

Acute rheumatism is, in this climate, rather a rare disease. In a practice 
of seven years I have treated but two cases. They both proved fatal. My 
notes of the cases are very imperfect; but as to both of them I administered 
quinine;, and as its applicability to the treatment of this disease is now being 
discussed, I am induced to mention the result, and to give such a detail of 
them as I can gather from my very brief notes. 

Case XI. — Acute Rheumatism^ fyc. July 16th, 1841, I visited J. G. L, 
a stout, robust carpenter, of rather intemperate habits, and found him suffer- 
ing under a very severe attack of acute rheumatism of the right knee. He 
had likewise severe pain in the right side, cough, and accelerated respiration, 
and percussion and auscultation gave evidence of the existence of pneumonia 
(in Stokes's third stage) in the lower lobe of the right lung. The stethoscope 
likewise gave indications of the existence of pericarditis. He had been sick 
five or six days, but up to the present time had refused to call a physician. 

My notes merely say, generally, that the remedies used up to the 23d were 
venesection, tartar emetic, calomel and opium, and blisters, without any 
abatement in the severity of the symptoms. On the 23d, before day, (at 

9* 



102 Boling on Inflammatory Affections of Malarious Districts. [July 

this time there was generally less febrile excitement,) I gave him an eight 
grain dose of quinine, and so much worse did he become in the course of the 
day that I was at the time, and am yet, disposed to ascribe to it an earlier 
termination of the case. 

He died on the 24th. On a post-mortem examination considerable in- 
flammation of the stomach and bowels was found, inflammation of the right 
lung, with hepatization of its lower third, and some shreds of coagulable 
l^'mph on the surface of the heart. 

Case XII. — Acute Rheumafis7n. S. M., a delicate lad, 11 years old, 
after having spent part of the two previous days fishing and wading through 
a small branch, was taken, on the 23d of April, 1841, with violent pain in 
the right knee, attended with great heat, swelling, and redness of the part, 
and with high febrile excitement. On the 24th his father took a small 
quantity of blood from his arm, and gave him a dose of castor oil, which 
operated well. On the morning of the 25th I visited him, and found him 
with a hard, quick pulse, knee so extremely painful that he could not bear 
the least motion in it, and he had not slept any in the last twenty-four hours. 
He icas not delirious, but there was a quickness in his manner, and a stern- 
ness of expression about his face altogether out of character with him. 

I took eight ounces of blood from his arm, and directed a grain of calomel 
and a quarter of a grain of ipecac, every second hour till his bowels should 
be freely evacuated. After I had bled him he seemed very much relieved, 
observing that his knee was quite easy, but complained of some pain in his 
head. The blood was very much buffed. 

I had scarcely reached home (a distance of two miles) before a messenger, 
who had been despatched a few minutes after me, arrived for me to visit 
him again in haste. I returned, and found him quite delirious, the knee 
much less red and swollen, and from the free manner in which he moved it, 
must have been much less painful. I had his feet and legs immersed in 
warm water; applied a sinapism to the knee, and blisters to the calves of his 
legs, and bled him again to about four ounces; continued the former pre- 
scription, with directions ; after it operated to give him four grains of Dover's 
powder. 

On the morning of the 26th he awoke out of a nap, which had lasted four 
hours; quite rational, and in every respect appeared a little belter; but knee 
more painful and swollen than yesterday. .On the 27th he continued much 
the same, but was delirious for a few minutes always when he awoke. Pain 
and swelling of knee again diminished, but he complains a good deal of the 
space between the knee and hip. On the 28th his left elbow became very 
hot and painful, and very much swollen, and the pain in his thigh and knee 
subsided almost entirely. Up to the 30th he was treated principally with 
calomel, colchicura, tart, emetic, and Dover's powder, and the severity of 
the disease, with the exception of the relief of the delirium, but slightly 
diminished. He had an enlarged spleen, lived in a highly malarious locality, 
and had once, every twenty-four hours, a slight abatement in the febrile 
excitement. On these grounds I determined to give him the quinine, and 
accordingly prescribed two grains every two hours. Under its use he cer- 
tainly appeared to improve. His pulse which, up to this time, had ranged 
from 130 to 140, was speedily reduced to 112; his skin became moist, and 
his thirst less intense; his knee became entirely easy, and his elbow very 
much relieved. On the 31st he continued much the same. Dr. Ames saw 
him with me, and advised a continuation of the quinine, two grains every 



1844.] Boling on Inflammatory Affections of Malarious Districts. 103 

third hour. On the morning of the 1st of May I visited him, and found 
him, as I thought, in a very favourable condition. His pulse was a little 
over 100, full and soft; skin moist, and he w^as, and had been for the last 
two days, rational at all times. I left him under the impression that he was 
doing well. About half an hour after I left him he was raised up in tied to 
take a drink of water, fell back suddenly and expired in a few minutes. At 
no time during the progress of the case did the stethoscope give any indica- 
cations of disease of the pericardium or heart. 

Remarks. — The first of these cases was certainly a very bad one, and pro- 
bably would not have recovered under any treatment. As to the immediate 
cause of death in the latter I cannot pretend to decide. 

The administration of the quinine would probably be condemned by a 
large majority of the profession, and, in all probability, most strongly by 
those who are practically least acquainted with the remedy, and whose 
knowledge of it is limited to some theoretical notions, founded upon its sup- 
posed highly stimulant properties. I do not think that the result of this case 
alone would deter me from using it again in similar cases. 

The following cases will probably be considered out of ^lace in an article 
on inflammatory affections. I give them, however, as interesting specimens 
of a few of the various forms which malarious diseases assume. 

Case XIII. — Bemittent Fever — Gastro-enteralgia, ^c. August 19th5 
1843. — John Mitchell, 40 years old, says that on the 15th and 16th he had 
slight fever, with most intense pains darting through the right side of his 
head, both coming on about noon, and lasting till after midnight. On the 
19th, at the same hour, his fever and headache returned, together with most 
excruciating pains in the abdomen, more fixed and severe in the epigastric 
region than elsewhere. The headache and abdominal pains declined about 
midnight on the occurrence of seven or eight large, thin, yellow evacuations 
from the bowels. The fever abated but did not go entirely off. Yesterday, 
at the usual hour, he had an exacerbation of fever, and a return of the ab- 
dominal pains without the headache, as on the night before the paroxysm 
declined on the occurrence of a profuse diarrhoea. Now (19th, 10 o'clock, 
A.M.) tongue natural; pulse 100, soft, and moderately full; skin moist; 
spleen very much enlarged, reaching an inch to the right of the umbilicus 
and to left iliac fossa. This he says has been so, or nearly as large, for ten 
years. II. Hydrarg. subm., gr. x; morph. sulph., gr. ss. — M. to be taken 
immediately; sinapism to abdomen. Evening. — His fev^r rose at the 
usual hour, but he suffered scarcely any from abdominal pains till about two 
hours ago, and they are much less severe than heretofore. R. Quin. sulph. 
3ss; extract, taraxaci, grs. x. — M. fiant pilulse x; two of them to be taken 
every second hour, commencing at 2 o'clock to-morrow morning. 

Aug. 20th. Is comparatively comfortable; pulse 90; as usual the abdo- 
minal pains went off last night with diarrhoea. Evening. — Same; no pain 
to-day; repeat quinine to-night. 

2l5^ At 9 o'clock last night he was taken with a violent pain in the ball 
of the right eye, which continued till midnight. 

22c/. Neither fever nor pain to-day. 

Under the use of grs. xv of qu'inine three times a day, for about a week, 
his spleen diminished so much in size as scarcely to be felt. 



104 'BoYmg 071 Inflammatory Affections of Malarious Districts. [July 

Case XIV. — Tertian Remittent Fever, with Cerebral Congestion. August 
1st, 1844. — James English, a stout robust Irishman, who has resided in this 
country something less than a year, and has laboured in the field a good deal 
during the past summer, has complained for several days of headache, fulness 
and oppression about the epigastrium, nausea, and want of appetite. Occa- 
sionally, for a day or two back, he has been quite feverish. He has had at 
no time a well-marked chill, but has had occasionally, at irregular intervals, 
slight chilly sensations. This evening, at 4 o'clock, he was taken with high 
fever, quickly followed by complete coma. I saw him first at 9 o'clock at 
night. Pulse 120, full, but not hard; great heat of skin; face flushed and 
head very hot, and violent throbbing of the temporal and carotid arteries ; 
breathing full and deep, and when he lays on his back, slightly stertorous ; 
he cannot by any means be roused to take the least notice, or give an answer. 
I bled him to about twenty ounces, after which his pulse became quickened, 
smaller, and softer, but without any abatement in the stupor. With difficulty 
I got him to swallow a cathartic of calomel and compound extract of colo- 
cynth, softened and mixed with syrup; I likewise directed an enema to be 
given every hour or two through the night, till his bowels should be freely 
evacuated; cold applications to his head; warm pediluvia and sinapisms to 
his ankles, and left him for the night. 

Aug. 2d. Altfiough his bowels have been freely evacuated, the stupor 
remains undiminished; pulse the same ; tongue dry and coated in the centre; 
pupils a good deal dilated, but readily affected by light; he makes no com- 
plaint, and gives no evidence whatever of pain; his evacuations were passed 
unconsciously. I bled him to ten ounces from the temporal artery, which 
had the effect of again quickening, temporarily, and rendering small and 
softer his pulse, without any perceptible effect on the stupor; I directed a 
blister to the back of his neck, and the enemata to be repeated occasionally 
through the day. Evening. — -Pulse 116; slight diminution in the heat of 
skin ; in other respects the same ; he has had several evacuations from his 
bowels, passed unconsciously. As he had not urinated since the attack, I 
introduced a catheter and drew off a few ounces only of highly coloured urine; 
continue cold applications to the head ; reapply sinapisms to extremities, and 
repeat warm pediluvia. 

3d. He is awake, perfectly rational, and says he feels quite comfortable ; 
tongue a litde moist; pulse 100; slight headache; temperature of skin a 
little above the natural standard. From the time I saw him yesterday even- 
ing the febrile excitement gradually abated till about 6 o'clock this morning, 
when he awoke, as if from a deep sleep. Not doubting that if something 
effectual was not done to prevent it, a recurrence of the paroxysm would 
take place in the evening, I prescribed twenty-four grains of quinine to be 
divided into three portions, one to be taken every second hour. Evening. — 
He is now in precisely the same situation in which I found him on the even- 
ing of the first, — the exacerbation, instead of coming on in the evening at 
4 o'clock, as I expected, anticipated it by several hours, and came on at 
10 o'clock in the morning, the time he should have taken the second dose of 
quinine. There was then but a brief and imperfect remission in the fever, 
and an intermission in the stupor of only four hours. This exacerbation 
pursued precisely the same course as the preceding, with the difference 
only of an increase in the stertor. 

On the evening of the 4th a slight diminution in the frequency of the pulse 
and temperature of the skin had taken place, and looking upon this as indi- 
cative of the approaching remission, which, however, might be very brief, I 



1844.] Boling on Inflammatory Affections of Malarious Districts. 105 

determined to take advantage of it, and as it was now impossible to get him 
to swallow any thing, directed an enema, containing 3ss of quinine and ten 
drops of laudanum, to be given every second hour. 

^th. Four of the enemata have been retained. He is awake, and much as 
he was on the morning of the 3d ; his pulse, however, is only 90, and he 
complains of tinnitus aurium. Looking upon this as an indication that 
liis system was under the influence of quinine, I felt perfectly easy about the 
case, but directed four grains of quinine every second hour. Evening. — 
Pulse 82; very little morbid heat of skin ; tongue moist; scarcely any thirst. 
Continue quinine, four grains every third hour. 

&Ji. Pulse 76; some appetite; no thirst. He received no further at- 
tention. 

Case XV. — October 13th, 1841, T visited Stone, a negro girl, about 

9 years old. She was, to all appearance, in a calm and gentle slumber; her 
pulse, and respiration, and temperature of the skin natural, that of the head 
and face being no greater than that of the other parts of her body; no in- 
creased action of the temporal or carotid arteries; pupils natural; tongue 
moist, and giving no indications of fever or gastric derangement. Her 
bowels, 1 learned, were in a good condition, the evacuations being perfectly 
natural. In short, there was no appearance of disease about her except the 
coma, and that might have been mistaken for a gentle and refreshing slumber 
but that she could not be roused from it. Loud noises, shaking her, the cold 
douche, and sinapisms, were all tried without effect. She lay perfectly 
relaxed, and made no effort to alter any position in which she might be 
placed. 

She was first taken about 9 o'clock on the morning of the 11th, the parox- 
ysm continuing till 2 o'clock in the morning of the 12th. A physician who 
had been sent for the night before saw her soon after the subsidence of the 
paroxysm, but as she was, to all appearance, in perfect health then, he made 
no prescription for her. At 9 o'clock on the 12ih she again fell into the 
same condition, the paroxysm continuing as before till about 3 o'clock on 
the morning following, when a complete intermission again occurred, in 
which she appeared in perfect health. About 11 o'clock on the morning of 
the 13th, when I lirst saw her, she was in the third paroxysm, which, like 
the two preceding ones, had come on about 9 o'clock. 

I ordered enemata, each to contain gr. v. of quinine, to be given every 
third hour till the occurrence of the intermission, which, with perfect confi- 
dence, I expected to come on as heretofore. During the intermission she 
was to take gr. iv. of quinine every third hour till she had taken three doses, 
and after that it was to be given in smaller doses, and at longer intervals, 

I visited her again on the 14th, in the afternoon. I found no appearance 
of disease about her. Her pulse, under the influence of quinine, was a little 
below the natural standard, being only 68. On the previous day, during the 
time of the paroxysm, it was 80. She had no return of the coma. 

Remarks.— The occurrence and regular periodical return of coma, during the 
progress of an attack of remittent fever, is by no means rare. But the form of 
disease above described, is, I am disposed to believe, of very rare occurrence. 
I have seen three cases of it, and one of my medical friends has spoken to 
me of one or two cases of it which have happened in his practice. It differs 
from the ordinary comatose remittent and intermittent fevers, in the absence 



106 Boling on Inflamraatory ^Bffections of Malarious Districts. [July 

of all febrile excitement, general constitutional disturbance, and appearances 
of determination to the brain. The case is a curious one. There was nothing 
like inflammation of the brain, and except the coma, there was nothing what- 
ever that could be taken in evidence of congestion. The functions of the 
brain were probably suspended by the noxious agent in a manner analogous 
to that by which local neuralgic affections are produced by it. 

I have not, in the selection of the above cases, chosen those only in 
which the beneficial influence of the quinine has been most conspicuous ; I 
have rather desired to exhibit, in a small space, as great a variety as possible 
in the character of the cases to which it is applicable. I could have given 
many others of the same kind, some of them, indeed, because fewer other 
remedies were given in conjunction with it, in them, exhibiting, if possible, 
still more unequivocally, its beneficial influence. That I do not attach undue 
importance to its agency, the progress and result of the cases prove, and 
that it is not a hobby very severely ridden is, I think, evident from the fact, 
that though freely used, and principally depended on, it has not, as a general 
rule, been to the exclusion of other remedies which seemed to me applicable 
to the eases. 

As to the best time for administering the quinine, I generally, in cases 
where there is any thing like a distinct remission, prefer this period for its 
commencement, probably now, more from habit than any thing else, where 
the remissions are short, or when the case is urgent, and there is reason to 
apprehend a fatal termination in the next exacerbation. Or where the disease 
is of so violent a character as to justify fears of the occurrence of any serious 
organic lesion, or a considerable aggravation of any that may already exist, 
it seems to me preferable to commence with it immediately, and this I gene- 
rally do without regard to the stage of the paroxysm. As to the doses, they 
should be efficient; but very large ones are generally unnecessary, and they 
are only advisable where a severe exacerbation is expected, and the time 
allowed you to guard against it is short. To an adult, in a case in which its 
continued administration, for a length of time, is advisable, for the purpose 
of subduing local inflammation, by its sedative influence over the heart and 
arteries, about forty-eight grains in the twenty-four hours will generally be 
found sufficient; and it is better to give it in doses of about eight grains every 
four hours, than to administer it in smaller doses at shorter intervals. The 
length of time for which it should be continued varies according to the cha- 
racter of the case. In remittent fevers, in which any local aff'ection that may 
be present, — e. g,, the congestion of the brain in comatose remittent fever, — 
subsides entirely during remission, its continuance merely for a sufficient 
length of time to prevent an exacerbation is all that is necessary, the progress 
towards recovery, however slow, being almost always certain from this 
point; where, however, there is inflammation present, the remedy should 
be continued till it is entirely subdued ; as frequenfly, when any spark of 
inflammatory action remains unextinguished, as soon as the influence of the 



1644.] Boling on Inflammatory Affections of Malarious Districts. 107 

quinine over the arterial system subsides, the inflammation is quickly rekin- 
dled, and its progress generally very rapid. 

The system once fully under the influence of the remedy, under any cir- 
cumstances, it seems to me better gradually to withdraw it. Even in severe 
cases of congestive fever, where great prostration, restlessness, and anxiety 
exist, — where the pulse is very frequent, small, and weak, and the extremi- 
ties bathed in a cold and clammy perspiration, and where each dose of the 
so called stimulant augments, in a high degree, these very symptoms which 
it is administered to combat, — I think that i have seen bad results follow its 
sudden withdrawal. In consultation, in such cases, I advise its continuance, 
the doses to be gradually diminished, but combined with full doses of some 
genuine stimulant. 

From these remarks I do not wish the inference to be dr^wn, that I look 
upon quinine as always injurious in congestive fever. On the contrary, I 
view it, even in this disease, when early administered, and with a proper 
knowledge of its real action, as the only remedy, so far as my experience 
goes, on which we can found any reasonable hope of cure. Under the use 
of other remedies I have sometimes seen cases get well, but it is only with 
this that I ever have any hopes of effecting a cure. 

, An attack of congestive fever is, like the mildest case of remittent fever, 
composed of a series of paroxysms, and these paroxysms of exacerbations 
and remissions, and like it, too, the progress is always one of improvement 
(except in the last fatal paroxysm) from the commencement of the decline of 
one exacerbation till the occurrence of the next. Prevent the occurrence of 
this exacerbation, and the progress towards amendment is continuous, till 
convalescence is established, in about the same ratio as during the decline of 
the previous exacerbation. It is sometimes, indeed, difficult to detect or 
distinguish the different stages of the paroxysms; for even in that moment 
in which the remission is most perfect, the patient's situation is sufficiently 
desperate. 

From what I have said, it is apparent that I believe the beneficial influence 
of quinine, in such cases, to be excited by a property which it possesses, 
altogether distinct and different from its antiphlogistic or sedative action. I 
allude to its power of preventing the recurrence of the paroxysms of peri- 
odical diseases. 

Its administration in congestive fever then, should be with the object 
solely of preventing an exacerbation, and thus allowing the efforts of nature 
to go on uninterrupted from the time of the decline of the previous paroxysm. 
With this object in view its administration can generally be conducted with 
safety, in the less severe cases, by giving no more than is necessary for this 
purpose, and then gradually withdrawing it; and in the more severe cases, 
where the prostration is extreme, by giving it in the same doses, with the 
same object only in view, in combination with some active stimulant to 
counteract its depressing influence. Thus, in the treatment of inflammatory 



108 Boling on Inflammatory Affections of Malarious Districts. [July 

affections, its sedative or contra-stimulant properties are aided by combining 
it with antimonials, and a general antiphlogistic course, while in cases of a 
congestive character its mysterious powers, as an agent against the periodical 
recurrence of morbid action, may be brought into play, and its depressing 
influence measurably prevented by combining it with stimulants. 

It is where it has been given as a stimulant that I have seen its baneful 
influence manifested, in cases of great debility; and it is astonishing with 
what perseverance it is sometimes administered, while each dose is speedily 
followed by an increase in the exhausting perspiration, prostration, and 
weakness and quickness of the pulse. 

In the few cases of this character in which the extract, the tincture, or the 
infusion of the Peruvian bark can be retained on the stomach in suflicient 
doses, it is preferable, as being less directly sedative, and possessing all the 
power, as an anti-periodic, of the quinine. In no article in the materia 
medica, however, is there more difference between the action of the genuine 
article, and the sophisticated compound sold by many of our druggists in- 
stead, than in the Peruvian bark. 

I have said that in a very few cases I have seen the quinine appear to act 
as a stimulant, and yet, in these instances, a further experience with the 
remedy has disposed me to think that the increased excitation follovring its 
administration, was attributable to other causes, perhaps only the natural 
progress of the disease. The action of the quinine may have been merely 
negative, as often happens in the administration of other remedies for dis- 
eases, in which, from the experience of ages, they have been sanctioned 
by the general voice of the profession. In cases of a highly inflamma- 
tory character, the doses of tartar emetic, which would be effectual in a 
less phlogistic state of the system, prove entirely nugatory. The patient 
who, in an ordinary attack of fever, would be excessively vomited by half 
a grain of tartar emetic, in a severe attack of pneumonia, will bear, some- 
times even without nausea, from half a grain to a grain of the same remedy 
every hour, for several days in succession. May it not be so with the 
quinia, that, to procure its beneficial influence, the size of the dose must be 
augmented in proportion to the amount of inflammatory action and febrile 
excitement which it is intended to subdue or resist? I have seen many 
facts confirmatory of this. 

The following case of bronchitis, verging into pneumonia, I have treated 
since writing the above. I append it as strongly and most unequivocally 
demonstrating the sedative or antiphlogistic powers of the quinia in a case in 
which there was scarcely a probability that the patient laboured under the 
influence of malaria. 

Case XVI. — December 25th, 1843, I visited Northcott, a strong 

muscular man, about 45 years old. He is a citizen of the state of Tennessee, 
and of a part of it in which, he says, fever and ague, and bilious remittent 
fevers, are unknown. On the 22d of November he started from home with 



1844.] Boling on Inflammatory Affections of Malarious Districts. 109 

a drove of hogs, and got wet and very much chilled by a heavy shower of 
rain the same day. Next morning he awoke with a troublesome cough, 
fever, difficulty of breathing, and some pain and a feeling of tightness in the 
chest. He continued to travel, however, with his drove, till about the 15th 
December, getting wet again several times during his journey, and each time 
" taking fresh cold." On the 15th he was compelled to lay up, but in two 
or three days, feeling a little better, he resumed his journey, and arrived in 
Montgomery on the 20lh. On the 23d, contrary to his inclinations, he was 
forced to take his bed, and on the 25th I visited him. He is not much ema- 
ciated, and he states that to within the last eight or ten days his appetite has 
been pretty good. Of late he has been more feverish, and has had occasion- 
ally chilly sensations, at irregular periods, brought on generally by a draught 
of cold water, or by contact with the cold bed after changing the sheets, &c. 
These chilly sensations have always been followed by periods of increased 
febrile excitement of irregular duration, and these again by perspiration. 
His cough is severe, and comes on in violent paroxysms, accompanied by an 
opaque, viscid, yellowish expectoration, in considerable quantities. Over 
nearly the whole chest a loud scattered sonorous riile is heard during expira- 
tion, and to the same extent during inspiration, a sibilous rale is heard. Over 
a space as large as one's hand, below the right nipple, a rather coarse crepi- 
tating rale is heard, and over a still greater extent on the lower part of the 
right side. It is only from the fourth rib up to the clavicle on each side that 
the respiratory murmur can be heard at all distinctly through the sonorous 
and sibilous rales. He complains much of soreness and tightness around 
the chest, and also of headache; tongue rather dry, rough and white; skin 
hot; pulse 100, and moderately full and sharp; respirations 30; face flushed 
and livid; bowels costive; catches at imaginary objects during his sleep; 
owing to the severity of his cough, he has for some time rested badly, more 
especially for the last three or four nights; he is quite thirsty. K, Ant. 
potass, tart., gr. ii ; Tr. opii, gtt. xxiv; mucilage -acaciae, ^iv. — M.; a table- 
spoonful to be taken every second hour; and li. Calomel, pulv. ipecac, c. aa 
gr. V. — M.; to be taken at bed-time. 

26//i. His situation remains much the same; pulse 100; respirations 28; 
skin hot ; he has had one thin bilious evacuation. Continue the antimonial 
mixture. Evening. — Same. Continue same. 

21th. Still as he was. R. Ant. potass, tart., gr. iv; Tr. opii, 5ss ; muci- 
lage acac, .^iv, — M.; a tablespoonful every third hour. Under a continua- 
tion of the same treatment his symptoms continued unabated up to the 
evening of the 28th, with this difference only, that he had got rid of the 
chilly sensations, and the consequent febrile paroxsyms, the fever being con- 
tinuous; yet judging from his own sensations he thought himself decidedly 
worse. At 7 o'clock in the evening I gave him, as an experiment, ten grains 
of quinine. At 10 o'clock I returned, and found a very appreciable improve- 
ment in him. His pulse 94; respiration 26, and his skin a little moist. 
R. Quin. sulph., gr. xxiv; massas hydrarg., gr. viii. — M.; fiant pilulse viii ; 
two of them to be taken every second hour. 

29/A. Pulse 86; respirations 26; skin and tongue moist; no thirst; cough 
less frequent; tinnitus aurium. Continue pills. Evening. — Pulse 78 ; respi- 
rations 26. Continue pills. 

30///,. Through forgetfulness the pills were not procured for him last night. 
The tinnitus aurium has abated; pulse 86; respirations 28; cough more 
troublesome; skin dry. R. Quinia? sulph., gr. iv; antim. potass, tart., gr. i; 

No. XV.— July, 1844. 10 



110 Boling on Inflammatory Affections of Malarious Districts. [July 

massse hydrarg-., gr. viii. — M. ft. massa in pilulas viii dividenda; two of 
ihem every third hour. Evening. — Pulse 76 ; respirations 26 ; skin moist. 

'6\st. Pulse and respirations the same; coughs but little, and with scarcely 
any expectoration. The sibilant rale is only heard occasionally at distant 
points; the sonorous rale continues to be heard extensively; the crepitating 
rale is heard over a small spot below the nipple. Continue pills. 

January 1st. Pulse 72; respirations the same; skin and tongue moist; 
cough and expectoration both diminished, and the small quantities of matter 
expectorated is a thin transparent mucus resembling that of the first stage of 
bronchitis. Continue pills. 

2(L Pulse 70 ; respiration and other symptoms the same. Continue pills. 

3^. Pulse 68, soft; skin and tongue moist; no thirst; scarcely any cough; 
no morbid sound in chest. Continue pills. 

4th. Pulse 64 ; respirations 24; some appetite; gums a little sore. He 
continued to take the quinine, gr. viii, three times a day for a short time. 

On the 7th he was able to sit up part of his lime ; he continued to im- 
prove, and recovered his strength rapidly. 

Remarks. — If the above case was really, as I have supposed, one in 
which malaria had no agency, its addition renders my heading somewhat 
inappropriate, and goes far to upset an opinion which I once entertained and 
hinted at in the commencement of this paper, — viz., that it was only on 
patients labouring under the poisonous influence of malaria that the sedative 
action of the quinia was exerted. This implies a belief in some peculiar 
modification of the system by the malaria, altering its susceptibility to the 
action of remedies, or in the possession of the quinia of a power, as a 
counter-poison to the malaria. Supposing the latter to be the case, the 
malaria, once decomposed or neutralized by the quinine, the derangement of 
the system produced by its action, provided it does not extend to disorgan- 
ization, subsides as a necessary consequence. However, to return, — the 
above case, I say, goes far to controvert such an opinion, and to establish 
the correctness of the proposition, that under any circumstances the quinine 
may be made to act as a sedative by merely proportioning the dose to the 
degree of inflammatory action going on in the system at the time. 

The peculiar applicability of the quinine to the treatment of the inflamma- 
tory affections of malarious districts, is owing to the combination, with its 
antiphlogistic properties, of a power as an agent in controlling the periodicity 
of morbid action. As an antiphlogistic remedy in elevated and healthy 
localities, it will probably never supersede the lancet, antimonials, &c., 
though it may, in many cases, be brought to their aid ; but in malarious 
regions, ere long, it will generally be looked upon as the safest and most 
manageable contra-stimulant we possess, and at the same time one suffi- 
ciently powerful, while other agents of the same class will only be used to 
fulfil some casual indication, or as adjuvants to this, the principal remedy. 



1844.] Perry's Case of Osteosarcoma of the Lower Jaw. Ill 



Art. VI. — Case of Osteosarcoma of the Lower Jaw — Excision — Cure. 
By Joseph P. Jervey, M. D., of Charleston, S. C. [With a wood-cut.] 

In November, 1842, Mr. M. called upon me to request an examination 
of his servant George's face. There was no hesitation in pronouncing the 
case to be one of osteo-sarcoma of the inferior jaw on the right side; the 
tumour was, at that time, not larger than a common hen's egg. I advised 
an immediate operation for the removal of the diseased portion of the jaw, 
but in consequence of the unwillingness of the patient to suffer the pain, his 
master very properly yielded to his repugnance. In December, 1843, Mr. 
M. again called and stated that 

of my professional friends, in 

the presence of the class then attending the lectures in the Medical Col- 
lege of the State of South Carolina. 

I commenced by making a free incision from the angle of the mouth on 
the right side directly down to the inferior border of the lower jaw, thence 
along the edge of the bone to a little above, and in front of the meatus auditorius 
externus. Having careftdly dissected up the whole of the right cheek, which 
by the way, was the most tedious portion of the operation, the exceeding 
vascularity of the tumour rendering it necessary to tie some vessel at almost 
every stroke of the knife, I divided the bone at the chin, and again above 
the angle of the jaw, removing the portion between these points with which 
the tumour was connected. 

The patient was on the table rather less than three quarters of an hour, by 
far the greater portion of which time, however, had been expended upon the 



112 Perry's Case of Osteosarcoma of the Lower Jaw, [J"ly 

bleeding vessels peculiar to the tumour. There was great prostration from 
loss of blood, and very slight reaction when dressed about three hours after 
the operation. In dressing the patient I made use of a silver plate, which 
bad been carefully moulded so as to form an exact receptacle for the teeth of 
the upper and lower jaw of the left side, leaving a small space between the 
jaws through which food, &c. might be introduced. This plate has been of 
very great service, as the lower jaw is now in its natural position, instead of 
being sunken and drawn to one side, which must have occurred without this 
support. 

January ^th. Took brandy freely during the night, and with the assist- 
ance of opium passed a comparatively comfortable time. Reaction pretty 
well established. 

Continued to improve until the 7th, when he complained of some uneasi- 
ness in the throat, and of having had a sleepless night. 

8^/i. Difficulty of swallowing much increased, and great complaint made 
of pain in the throat. Upon removing the dressings (for the first time) the 
wound was found to be disposed to heal throughout its whole extent, and the 
interior of the mouth was suppurating, and of a healthy appearance. 

On the 10th removed the pin from the angle of the mouth, and the stitches 
from the wound, which looked well. Great complaint of the throat still, 
and difficulty in swallowing. 

No material change occurred until the 14th, when, upon visiting my 
patient, I was surprised to find a great improvement in his speech; he ex- 
pressed himself as, "feeling like a new man." Upon examination I dis- 
covered that an abscess had opened in the throat during the preceding night, 
and had discharged freely, and he was immediately relieved from all pain 
and difficulty of swallowing. 

Complained on the 20th of great pain in the legs, which was followed on 
the 21st by a dropsical swelling of the legs and feet, extending on the 22d to 
the trunk, the belly being much distended. The dropsical swelling continued 
variable until the 1st February, when the patient was carried to his master's 
plantation, in the neighbourhood of the city, with directions to continue the 
same remedial course which had been employed during his stay in the city. 

On the 16lh February I visited George, and saw a very marked improve- 
ment in every respect. 

I again saw him on the 9th March, and found that he had voluntarily gone 
to work. The swelling on the right side of the face has almost entirely dis- 
appeared, and upon examining the mouth I traced a deposit, sufficiently firm 
to resist the pressure of the finger, uniting the divided ends of the jaw bone, 
and filling the space formerly occupied by the bone. 



1844.] HMreiWs Case of Craniotomy, 113 



# 



Art. VII. — Case of Craniotomy. By Charles C. Hildreth, M.D., of 

Zanesviile, Ohio. 

Mrs. D. C, residing four and a half miles from Zanesviile, was referred 
to me by Dr. S., who had been several days in attendance, but whose other 
engagements compelled him to decline the case. 

Jan, Slst, 1841. Found Mrs. C. in tolerably active labour with her first 
child. She informs me that she has suffered almost constant pain for a week 
past, and that during that time Dr. S. had been in attendance three nights 
and part of two days. Making the usual vaginal examination, I found the 
membranes ruptured, the os uteri dilated to the size of a half dollar, and the 
posterior fontanelle to the right acetabulum. The conjugate diameter of the 
pelvis somewhat contracted. There being unusual rigidity of the external soft 
parts, OS uteri, and the pulse justifying the measure, I bled her to approaching 
syncope ; relaxation followed^ and dilatation of the os uteri progressed more 
rapidly. At 10 P. M. the vertex became fairly engaged in the upper strait. 

For the next three hours the labour made no progress, and the pains became 
inefficient. The os uteri being now sufficiently dilated, and the soft parts 
relaxed, at 1 A. M., Feb. 1, I gave the ergot. Under its influence the uterus 
contracted much more energetically, and some little progress was made. 
The head was forced fairly into the upper strait, but could not be made to 
engage in the lower. The ergot was repeated after the effect from the first 
dose was lost, but with the result only of wedging the head more firmly 
against the pubis and promontory of the sacrum. Its influence, in fact, was 
soon lost entirely, from diminished nervous energy of the uterus, the result 
of its long-continued action. 

Finding the child could not be born by the natural efforts, nor by the use 
of ergot, I sent to Zanesviile, about 4 A. M., for the long forceps. After their 
arrival, and the usual preparations, an attempt was made at their introduction. 
In the left side of the pelvis there was no difficulty found in introducing 
one blade of the forceps, and adjusting it to the child's head in the proper 
direction ; but under the arch and ramus of the pubis of the right side I 
found the head impacted so firmly, that by no prudent effort could I get the 
blade in apposition with the head so that I could lock the instrument. With- 
drawing the forceps I introduced the vectis, and co-operating with the expul- 
sive efforts of the patient endeavoured to enlarge the space under the pubis, but 
in vain. Examining carefully the condition of my patient, I found her much 
exhausted; pulse 140; uterine action nearly suspended; strength failing; 
symptoms of impacted head manifest; vagina and labia swollen and irritable. 
Becoming alarmed for her safety, I requested a consultation, and named Dr. 
S., as he had been previously in attendance. 

The consulting physician was requested to bring other forceps and instru- 

10* 



114 HMreih's Case of Craniotomy, [July 

ments for opening the head. Gave the patient brandy and nourishment, and 
allowed her to rest quietly until the arrival of Dr. S., at 7 A. M. The Dr. 
brought short forceps only^ having no embryotomic instruments. After giving 
the patient half a grain of morphine and more brandy, an attempt was made 
by Dr. S. and myself to adjust the short forceps, but unsuccessfully. The 
head upon the right side of the pelvis was too firmly impacted to suffer the 
blade to be placed in apposition with it. After several ineffectual efforts to 
deliver by the forceps (Dr. S. agreeing with me in the absolute necessity of 
craniotomy to save the life of our patient), the proper instruments were ob- 
tained as soon as possible, the head opened, the brain evacuated, the cranial 
bones removed, and by the assistance of the crotchet and the efforts of the 
patient, the child was delivered without any unusual difficulty. From the 
desquamation of cuticle, and other evidences of decomposition, we perceived 
that the child had been some time dead. After the' removal of the placenta 
the uterus contracted well under the use of the bandage. 

The tongue indicating some bilious derangement, we prescribed small 
doses of cal. and senna every four hours. Pills of opium and camphor, two 
grains each, were directed whenever required by \he pain or exhaustion, and 
brandy also, if necessary, with her nourishment. 

We took leave of our patient about 12 o'clock, with much apprehension 
of peritoneal or uterine inflammation, and extensive sloughing of the vagina 
from the long-continued and excessive pressure it had sustained. 

Feb. 2d. Found my patient had been purged excessively by the calomel, 
notwithstanding the liberal exhibition of opium; perspiring moderately; pulse 
125; thirst urgent; tongue dry; no after pains; abdomen very tender on 
pressure, but not swollen; lochial discharge natural; urine passed with pain. 
Directed the pills of opium and camphor, two grains each, every two hours, 
until the purging ceased; brandy, if required by exhaustion; mild nourish- 
ment; a vegetable diuretic infusion for drink; directed also frequent ablu- 
tions of the vagina with a solution of chloride of soda and warm water, 
thrown up with the female syringe ; fomentations to the hypogastric region 
of hops, flannel, and hot water; perfect rest and quietude. 

3c?. Found my patient rather more comfortable ; purging still continues; 
five or six evacuations in the last twenty-four hours. The opium had been 
taken every two hours as directed, is well borne, sustaining the pulse, and 
supporting the exhausted energies of the system more perfectly than could 
have been expected from any other agent. Pulse more developed, 120; no 
fever; still perspiring moderately; the warm vaginal injections somewhat 
relieve the difficulty of passing water. Continue treatment ; pills of opium 
and camphor every three hours as long as demanded by the purging, pain, &;c. 

4//i. Purging nearly ceased; vagina and labia much swollen, and very 
tender to the touch ; soreness of hypogastrium diminishing; pulse 120; no 
fever; no milk; feels rather stronger; tongue cleaning off and becoming 
moist; secretions from the bowels healthy. Directed the opium to be given 



1844.] HMreih^s Case of Craniotomy, 115 

as indicated; spts. nitr. dul. and camphor with the diuretic infusion for the 
relief of strangury. 

dth. Last evening had a chill, but no fever ; some slight appearance of 
milk. Informs rae that she felt distinctly last night something give way in 
the vagina, at which time also she fainted. Since that time she has had two 
discharges from the vagina, of matter d[s{inci]y feculent, and in considerable 
quantity, thus establishing beyond a doubt a slough of the recto-vaginal 
septum. Directed the parts to be kept clean by frequent injections contain- 
ing the chloride of soda. Discharge from vagina becoming pale, purulent, 
and offensive. Strength well sustained by nourishment alone. 

Qth. No further discharge of faeces from vagina or rectum ; symptoms 
nearly the same ; no fever; very litde milk ; another chill last night. Con- 
tinue treatment. 

7th. Complains much of strangury; says she has passed but very little 
water for twelve hours. Introduced the catheter; removed but half a pint of 
highly coloured urine. Nothing more has passed vagina or rectum; milk 
rather more abundant. 

lO^A. Lacteal secretion suspended ; perspiring too much. Directed the 
whole surface to be rubbed with hot alum and brandy twice daily. No 
evacuation from bowels for four days. Directed castor oil and enemata. 

I9th. Patient still very feeble; no fever; no milk; says slie has seen 
nothing more like faeces pass vagina ; still troubled with strangury; made a 
vaginal examination. Os uteri very tender to the touch, the organ, however, 
not larger than natural ; can detect no trace of fistula in the recto-vaginal 
septum, the whole surface, however, very tender to the touch, and irritable. 
Ejected weak injections of sugar of lead and laudanum ; hot poultices to 
hypogastrium ; horizontal posture. 

From this time my patient continued gradually to improve. She was kept 
in the horizontal posture for several weeks, and now, Jan. 2, 1844, although 
in the enjoyment of tolerable health she is still not well. 

The uterus has since laboured under inflammatory symptoms of a sub- 
acute character, as indicated by dysmenorrhoea, occasional pains in the back 
and loins, tenderness on pressure, &c. For this condition she has taken 
iodine, the deuto-iodide of mercury, and hydriod. potass, Donovan's mixture, 
&c. &c., but without any very apparent benefit. I have frequently urged 
upon her the use of leeches to the os uteri, but could never obtain her con- 
sent to their application. She has never since conceived, nor until the uterus 
can be restored to its healthy functions can such a result be anticipated. 
Before taking leave of this case I cannot avoid referring to one or two points 
connected with it, to me, at least, of great practical interest and value. 

And in the first place, we observe the strong reliance we should justly place 
upon the "vis medicatrix naturae" under circumstances the most unpromising. 
That a slough between the rectum and vagina occurred in this rase on the 
fourth day after delivery I have not a doubt. That a fistulous opening 



116 B.MYe\h's Case of Craniotomy. [July 

would follow I certainly expected, and had determined, at the proper time, 
to attempt its reparation. In this, however, I was most agreeably deceived. 
Under the simple agency of rest, quietude, cleanliness of the parts, &;c., 
nature did for my patient what too often the most skilful surgeon fails to 
accomplish, and relieved her at once of one of the most loathsome diseases 
to which human nature is liable. Another point of much interest in con- 
nection with this case is, the exceeding great value of opium in controlling 
inflammation of the uterus and its serous investment. The patient, it will 
be remembered, was kept completely under its influence for several days 
after delivery; twenty-four grains were taken on the second day; perhaps 
sixteen on the third, and yet the bowels were not constipated by it, five or 
six evacuations passing daily until the fourth day. 

The opium was borne remarkably well in this case, and to it I attribute 
my patient's preservation of life. It sustained the pulse, adding fulness and 
volume to it, at the same time diminishing its frequency. It allayed all pain, 
and by its calming and soothing influence upon the nervous and arterial sys- 
tems, kept down that strong tendency to inflammation which would naturally 
follow those grave lesions of structure and serious disturbance of function 
my patient had suff'ered. The following observation of Blundell was beau- 
tifully verified in her case, — That in cases of extreme exhaustion from loss 
of blood, protracted labour, and great impairment of nervous energy, the 
patient, when placed under the decided influence of opium, continues "to 
exist upon very small expenditures of the vital fluid." While the patient 
sleeps and dreams away her existence, the brain and nervous system, under 
the sustaining influence of the opium, gradually but securely recover from 
the shock they have sustained. In inflammation of many of the scrolls 
tissues, if we can allay pain by opium in large doses, we have gained a 
strong point towards the removal of disease. This is exemplified in pleurisy; 
here a large bleeding and a full dose of opium will often at once cut short the 
disease if given before eff'usion occurs. 

But to inflammation of the peritoneum is the remark more particularly 
applicable; here opium is one of our best remedies. Drs. Graves and Stokes 
(than whom I know no better physicians) inform us that they sometimes 
saved their patients by large and continued doses of opium, even after per- 
foration of the peritoneum from ulceration of the bowels. Cases are on 
record where life has been saved by the same means, and after rupture of 
the uterus, and escape of the child into the peritoneal cavity. But these of 
course are extreme cases. Again, many of the best modern surgeons rely 
upon opium in a great measure, in controlling inflammation of the perito- 
neum, which follows the extirpation o^ ovarian tumours or the Csesarian sec- 
tion. In inflammations of the peritoneum, occurring or supervening in states 
of great exhaustion, and where the more active remedies are inadmissible, 
is the opium practice found of the greatest value. Should, however, the brai7i 
be implicated, as a general rule, the use of opium must be abandoned. 

Zanesville, 0., ^pril 6, 1844. 



1844.] 117 



REVIEW. 



Art. VIII. — Traite Clinique et Pratique des Maladies des Enfans; par 
MM. RiLLiET et Barthez, Docleurs en Medecine, anciens internes lau- 
reats de I'Hopital des Enfans Malades de Paris, &c. &c. Tomes III. 
pp. 2375, 8vo. Paris, 1843. 

Clinical and Practical Treatise on the Diseases of Children. By MM. 
RiLLiET and Barthez, &c. 

The attention of recent observers in Europe, as well as in this country, 
has been strongly directed to the study of the peculiar modifications of 
disease which have at all times been observed during childhood, and a large 
amount of facts has been collected, both from their own investigations, and 
from the writings of earlier authors, which has been communicated to the 
profession in several complete treatises on the pathology of childhood. In 
France, however, no general work upon this subject had appeared to sum 
up the knowledge scattered through special dissertations, and in the pages 
of medical journals, when MM. Rilliet and Barthez, in 1837, conceived 
the plan of endeavouring to fill up this chasm in medical literature, by 
publishing a series of monographs upon the principal diseases of child- 
hood, and especially of that period " which extends from the end of the 
first year to puberty." 

They enjoyed the most favourable opportunities for the collection of valua- 
ble materials, in their position as internes, or resident physicians of the Ho- 
pital des Enfans Malades of Paris, and devoted their whole time and 
attention for several years, to the careful investigation of every circumstance 
connected with the cases which passed under their inspection, and which 
would throw light upon their pursuits. In 1838, their first monograph, 
on Pneumonia, was published in the Archives Generales de Medecine, 
and has been followed from time to time by other valuable ones; they 
were fortunately enabled subsequently to enlarge the sphere of their labours, 
in consequence of one of them beina: continued for two years longer in the 
hospital, after having sustained a brilliant and successful concours, and were 
thereby induced to undertake the preparation of the work which lies before 
us, in the prosecution of which task, they acknowledge their indebtedness 
to the kindness of the physicians under whom they served, for great faci- 
lities in conducting investigations, and to several former colleagues, for in- 
teresting cases. 

The authors tell us in the Preface, from which the above narrative is 
derived, that their chief aim is " to facilitate the study of the diseases of 
children, a subject full of difficulty, and to furnish a useful guide to the 
physician at the bedside of the sick." They also desire to contribute 
their proportion of useful materials to the history of pathology, by report- 
ing with circumstantial detail the facts relative to the pathology of child- 
hood, exclusively ; facts, which are the results of their own persona] 
observation, and for the accuracy of which they can therefore vouch. In 



118 Review. [Juty 

pursuance of this design, every case which appeared in the wards under 
their charge, during a period of several years, and at all seasons, was care- 
fully studied, every particular in each, however minute or apparently un- 
important, was scrupulously noted, and no pains were spared in preparing 
them for ultimate analysis. Laborious as was the task of collecting mate- 
rials for the work, it did not exceed in difficulty, nor require less patient 
perseverance than that of reducing tliem to order, and arranging them in 
such a manner as to present to the reader the results to which they led. 
The plan adopted for this purpose, after rejecting many of their earlier 
cases as being incomplete, was that which had been so successfully em- 
ployed by M. Louis, consisting in a statement of the number of cases 
under examination, and in a complete analysis of them, in tables, under 
every possible aspect. Had these tables been published in full, the authors 
feared that they would have justly incurred the charge of being unneces- 
sarily prolix ; they have, therefore, been content to give the results of 
these analyses and "succinct extracts from cases which had been collected 
in detail," when they were of sufficient interest, or were required for illus- 
tration. 

They have also compared with their own, the recorded observations of 
the principal writers of England, Germany, and France, and have thus 
been enabled to give a complete account of the history of these diseases, 
which, from the manner in which it is presented, possesses all the attrac- 
tions of novelty and originality, confirming in most cases the opinions 
of previous writers, at the same time that it opens up new views and 
considerations relative to the diseases of children. Such, then, is the 
plan upon which the authors proceeded in collecting and preparing their 
materials. The manner in which they were finally arranged, and the con- 
clusions that have been deduced from them, we are now to examine. 

In the introductory chapter MM. Rilliet and Barthez recognize the pro- 
priety of establishing periods in the duration of childhood, in the full 
belief that the diseases of that time of life are impressed with peculiar 
characters, according with the physiological development of the child, and 
they consider the age of the child as affording a proper distinction, as the 
usual division founded upon dentition, could not well apply to children 
who had all passed the age of 15 months. " The age of G years seems 
to form a sufficiently marked separation, for diseases often present a differ- 
ent aspect before, and after that epoch." Secondary divisions are laid 
down in each of these groups, children of from 15 months to 3 years, 
being distinguished from those between 3 and 6 years ; v/hilst those be- 
tween 6 and 10 years are sometimes noticed apart from those between 11 
and 15 years, this last period forming the transition from childhood to 
puberty. 

The general consideration of the diseases of children reveals the fact 
that they are but rarely simple, and that the same affection presents a 
very different aspect, when it occurs during good health, or in the course 
of some other disease. The authors also state, that 

"Diseases of the same nature have the greatest affinity for each other, mutu- 
ally and habitually engendering each other, provided they do not arise from the 
same cause; in which case the secondary affeciion may cure the primitive one; 
whilst those of an opposite nature generally repel each other, provided they do 
not recognize the same cause, or provided the first does not act as a local stimu- 
lus to the second. Hence, it is less important to study the seat than the nature 



1844.] Rilliet and Bartbez on the Diseases of Children, 119 

of the disease, when we compare the primitive with the secondary, and look for 
the laws of their concatenation." 

These diseases are also acute, chronic, or cachectic, the last developing 
themselves in children, either constitutionally feeble, or becoming so in con- 
sequence of a succession of morbid conditions. 

As a basis for classification, the nature of the disease, though not free 
from objections, of which the authors were fully aware, appeared more 
applicable in this case, because it enabled them to group together the facts 
they have collected in a manner, which was, at least, as judicious as 
any other. The classification of Pinel was, therefore, adopted in the 
volumes before us, after having been modified by the results of more re- 
cent investigations, and, especially by more accurate knowledge of the 
anatomical, pathological, and therapeutic affinities of disease. Thus we 
have 1st, Phlegmasiae ; 2d, Dropsies; 3d, Haemorrhages; 4th, Gan- 
grenes; 5th, Neuroses; 6th, Continued Fevers; 7th, Tuberculization; 
8th, Entozoa, which last was added by MM. R. and B. These are placed 
in such an order as that those which are habitually secondary may be first 
described, this arrangement being deemed most advantageous for the study 
of each disease. In these divisions or classes, many forms of diseases to 
which children are liable, are evidently unnoticed ; they are, however, 
either included under some of these heads, to which they bear the closest 
affinity, as congestion, hypertrophy and softening, under that of phleg- 
masioD, or they are passed over entirely, as belonging rather to the domain 
of surgery, as cancer, " which, by the way, is a very rare affection in chil- 
dren," rachitis, and the surgical affections proper. 

Secondary divisions, founded upon a local lesion, or local symptoms, 
are established in these 8 classes. " Thus in each of them, we study the 
diseases, 1st, of the chest ; 2d, of the nasal fossae, of the mouth, and of 
the neck; 3d, of the abdomen; 4th, of the encephalon and spinal mar- 
row; 5th, of the external organs, as the skin, the articulations, the geni- 
tal organs, the ears, &;c. The diseases of each organ will be the subject 
of a chapter in each of these sections." A full and careful exposition of 
the pathological anatomy, of the symptoms, of the diagnosis, of the com- 
plications, of the prognosis, of the causes, of the treatment and of the his- 
tory or bibliography of each disease is laid before the reader, and occasional 
remarks are added concerning its nature and its physiologie pathologique, 
when necessary for the purpose of elucidation or for the justification of 
opinions advanced. 

It should be remarked, besides, that, while MM. Rilliet and Barthez 
have neglected nothing of importance in reference to any of the above par- 
ticulars, so as to make complete monogi aphs of their description of each dis- 
ease, they have devoted especial attention to symptomatology and therapeu- 
tics, regarding the former as the " foundation-stone of diagnosis," and as the 
only true means by which, with an accurate knowledge of pathology, we can 
hope to lay down the proper indications for the treatment of disease. They 
have endeavoured to establish useful and detailed therapeutic rules, derived 
from their own experience and from a careful study of the writings of 
others, and especially of the Germans. The indications for treatment are 
well presented ; the modes of action, and the advantages to be expected 
from the use of each remedy proposed to meet these indications, are sepa- 
rately examined; and in a concluding paragraph to the account of each dis- 
ease, there is a "brief recapitulation of the different phenomena which may 



120 Review. [July 

be presented by children labouring under the same affection, and an indi- 
cation in the form of a simple prescription, of the treatment which appears 
best adapted to each form and period of the disease ;" a mode of proceed- 
ing which cannot but be regarded as highly commendable, and as adding 
greatly to the practical value of this work. 

We have thus placed before the reader an outline of this treatise, as it is 
sketched in the introductory chapter, and we will now proceed to examine, 
or rather to give an account of, the different subjects embraced within its 
pages, recalling, however, first to the reader, that infants, properly so 
called, are not included among the patients admitted to the Hopital des 
Enfans Malades, and are, therefore, not referred to in these volumes. It 
is due to the authors to bear this fact in mind, for it will enable us to 
account for statements which might otherwise appear contrary to generally 
received opinions, but which will, in fact, be found to be perfectly correct 
when examined with this restriction. 

Our attention is directed in the first place to that important class, the 
phlegmasiae, under which title, as before stated, are placed both for conve- 
nience, and with evident propriety, hyperaemia, softening and hypertrophy, 
A preliminary chapter introduces the subject of inflammation, summing up 
in an admirable manner all that is known relative to the organs it attacks, 
the peculiar forms it at times assumes, the symptoms by which it is revealed, 
and the treatment requisite to moderate its action and to effect a cure. 

The peculiarities of the phlegmasiae in children, as noticed by MM. R. 
and B. consist rather in a greater or less liability to certain anatomical and 
symptomatic forms, than in a dissimilarity of nature from those met with 
at a late period of life. It is also noticed that "their symptomatic and 
often their anatomical form, their seat and their distribution are modified by 
the condition giving rise to them ;" indicating an important principle in 
their treatment ; for, " if the lesion of the organ is taken as the sole guide, 
and the disease is attacked by the same remedy," whether the form be a 
primitive acute attack occurring during health, or either primitive or con- 
secutive in a weakened cachectic constitution, '* you exasperate it in the 
one case, and you relieve it in the other. The curative medication of in- 
flammation in children, must be directed rather according to the symptoms, 
than by pathological anatomy, which should take the second place in our 
consideration." Vol. i. p. 10. 

One of the most important facts to be noticed in the inflammatory attacks 
of children, is, 

"That they rarely remain isolated, succeeding each other with the greatest 
facility, or marching simultaneously, the one agtrravating rather than curing the 
other. * * * An inflammation existing in an oro-an may disappear, remain 
stationary, or increase under the influence of an inflammation developed in a 
more important organ ; hut the disappearance of the first inflammation is the 
exception to the rule, at the same time that the general condition is always ren- 
dered worse. * * * If on the other hand, an organ less essential to life is 
inflamed, and the same process is developed in another organ of less, or nearly 
equal importance, we are firmly convinced, that \\\e first inflammation will never 
or almost never be diminished, sometimes it will increase, and the second in- 
flammation will only prove an additional cause of death." 

The danger of using blisters, or even sinapisms, or any cutaneous 
revulsives in inflammation in children, follows as a corollary to this pro- 
position, the authors conceiving that they only cause additional pain and 



I 



I 



1844.] Rilliet and Barthez on the Diseases of Children. 121 

an excitement often useless for the relief of the internal affection, which 
will follow its fatal course, and may even be aggravated by this new in- 
flammation. We shall have occasion to advert to these opinions hereafter. 

A marked distinction is to be observed between those inflammations 
occurring in the course of previous good health, and those coming on in 
the midst of some other affection; each of these forms, again, may be 
acute, chronic, or cachectic, giving rise to the following divisions, under 
which inflammations are here studied. 

Primitive phlegmasiae with an acute type; 

Consecutive phlegmasiae with an acute type ; 

Primitive phlegmasiae with a chronic or cachectic type ; and 

Consecutive phlegmasiae with a chronic or cachectic type. 

Before leaving these general considerations, we would direct attention to 
two interesting particulars, mentioned by our authors. One is, that, as far 
their observation extends, and it is we believe in accordance with sound 
pathology, " Inflammation of the parenchymata rarely, we would wil- 
lingly say never, leaves atrophy as a result, having met with no example 
of it; hypertrophy, on the other hand, is, if not a frequent, at least, a pos- 
sible consequence of it." Vol. i. p. 8. The other, and it is a fact to 
which we find constant allusion in the pages of these volumes, is, "that 
the age, the sex, and the constitution of the child establish a great differ- 
ence in the predisposition to certain kinds and certain forms of inflam- 
mation ; thus, the youngest and most delicate children and girls are more 
subject to the chronic and cachectic forms, than older and more sanguine 
children and boys." Vol. i. p. 13. 

Among the inflammatory affections which occupy the first section, those 
of the chest are first presented to the reader's notice. Prominent among 
these, both on account of its frequency, and the different forms it assumes, 
stands bronchitis, a disease long confounded with pneumonia, and only 
recently studied apart from it. The principal facts upon which the chapter 
on bronchitis is founded, were originally published by the authors in their 
monograph on pneumonia, which was designed to give a complete history 
of that affection, in all its relations with other diseases of the lungs ; since 
then, many additional and important observations have been collected, and a 
valuable stock of nevv and interesting matter has been placed within their 
reach in the thesis of M. Fauvel on Capillary and Pseudo-Membranous Bron- 
chitis, which has corroborated their views and conclusions. These, how- 
ever, have long been before the public, and, having been found to coincide 
with those of other accurate observers, have been adopted in almost every 
standard work which has since been published ; we will therefore only 
point out a few of them. 

MM. Rilliet and Barthez state, that you rarely meet with the anatomical 
characters of acute bronchitis in a child under five years of age, without at 
the same time finding traces of pneumonia, this being sometimes a second- 
ary disease, at others primitive or concomitant. Connected with this, we 
are told that the value of the sub-crepitant rhonchus, as a diagnostic sign of 
bronchitis, differs with the age of the child in whom it is met with : thus 
if it is under five years, and the sound is heard either on one or both sides 
of the chest, there is danger of pneumonia existing as a complication of 
the acute bronchial inflammation, whilst after the age of five years, there 
is less probability of this being the case, though even here, from the ten- 
dency to the occurrence of lobular pneumonia, its presence may be sus- 
No. XV.— -July, 1844. 11 



122 Review. [}^y 

pected. Where the crepitant rhonchus is heard, the authors have invariably, 
with one exception, met with portions of the lung affected with pneu- 
monia. The local and general symptoms together, can alone afford a mea- 
sure of the gravity of the disease. This, when the affection is primitive, 
is comparatively slight; but, from the facility with which the inflammation 
extends to the whole of the bronchial tubes even to the minutest ramifica- 
tions, and with which it becomes complicated with pneumonia, it is always 
to be carefully watched and requires prompt treatment. When from the 
outset, the whole of these tubes are inflamed, the disease invading the 
smallest bronchi, constituting what is called the capillary form, accompa- 
nied with high fever, acceleration of the respiration and great dyspnoea, 
with a copious purulent and pseudo-membranous secretion, it is at all ages 
a serious disease; indeed, all the authors' patients and those of M. Fauvel, 
which were thus attacked, died ; and we are elsewhere told that " the great 
majority of those who died of bronchitis presented muco-purulent and 
pseudo-membranous secretions in the bronchi, especially in those of the 
lower lobe." In these severe cases, the employment of moderate bleed- 
ings, and emetics, and, especially, the antimonial preparations, with diffu- 
sible stimulants and cutaneous revulsives in the latter stages, is recommend- 
ed to be adopted ; in the milder forms, however, it will be only necessary 
to keep the children in bed, giving them mucilaginous drinks and slight 
antimonials, sedatives when the cough is troublesome, and emetics when 
the collection of mucus in the lungs is very great. 

The conviction that most of the readers of modern medical literature 
must be already familiar with the valuable researches of the authors on the 
subject of pneumonia in children, both from the able memoir to which we 
have already several times alluded, and from the excellent work of M. 
Grisolle on pneumonia,* into which it has been incorporated almost entire, 
induces us to attempt merely to recall some of the results of their investi- 
gation, and to state that their subsequent inquiries have only tended to 
confirm their conclusions. 

It has been asserted that bronchitis always precedes pneumonia in chil- 
dren, especially the younger ones; nor can it be denied that such is often 
the case, and that in a great majority of instances inflammation of the 
bronchi is found to occupy the smaller ramifications, co-existing with the 
lobular form, which is so much more frequent than the lobar at this period of 
life. The authors, however, believe that this bronchitis should be looked 
upon rather as a predisposing cause to the inflammation of the parenchyma 
of the lungs, than as an active occasional cause, and they state the results 
of their later researches upon this subject, as follows. 

"We admit, 1st, that lobar pneumonia, without bronchitis, in children under 
five years of age, occurs more frequently than was supposed in 1838; 2(1, that 
lobular broncho-pneumonia is much more frequent than simple lobular pneu- 
monia; 3d, that it is nevertheless incontestable, that lobular pneumonia, mamil- 
lated, partial or generalized, may exist in children without bronchitis ; and 4th, 
that inflammation of the bronchi and of the lungs is, in some cases, simultane- 
ous," Vol. i. p. 114. 

Lobular pneumonia is not only more frequent, but it is more serious 
than the lobar form. It occurs either in isolated separate lobules, or 
with a tendency to extend from these and generalize itself over the 
lungs, thus presenting a very grave form of disease. In the immense 

* Reviewed in the No. of this Journal for July, 1843. 



1844.] Rilliet and Barthez on the Diseases of Children. 123 

majority of cases it is double ; indeed, of 203 cases, it was single in only- 
five instances, and in these it was of little importance. The exceptions 
were cases in which carnification, — itself, in fact, a form of pneumonia, — 
existed in the opposite side, or in which the inflammation was developed 
around a tubercular deposit, or as the authors met with it sometimes, after 
scarlatina and variola, in which hepatized lobules — in fact rather resembling 
apoplectic nuclei — were found on one side only. This lobular form not rarely 
reaches the third degree, terminating in the formation of abscesses, varying 
from the size of a pin's head to that of a pea. These are sometimes met 
with in the lobar form, but very rarely, and are then larger. Lobar pneu- 
monia is generally single, most frequently developed on the right side, and 
at the base of the lungs. In one-third of the authors' cases they observed 
it in the upper lobe. In reference to this point, a curious statement is 
made by MM. R. and B.; they say, " that almost all the children (affected 
with pneumonia) which entered the hospital in April, May, and June, 
1840, were attacked with pneumonia of the summit, presenting, as it 
were, a sort of epidemic of this form, which is generally rare." We find 
repeated here a fact relative to diagnosis of pneumonia of the summit, 
which was first announced by the authors in their memoir in 1838, and 
which they assure us is confirmed by their subsequent observations. It is 
that inequality in the respiration, and especially an abrupt broken rhythm, 
(rhythms saccadee,) indicates almost exclusively this form of the disease, 
and that the attack sometimes commences with violent and repeated con- 
vulsions, often followed by loss of consciousness, which disappears after a 
time leaving a Considerable acceleration of the pulse and of the respiration, 
leading to a suspicion of a pulmonary aff'ection, which may be detected by 
other and more certain signs. This convulsive commencement of the 
attack is almost exclusively met with in this form of pulmonary inflamma- 
tion. 

That condition of the lung wliich has received the name of carnification 
from M. Rufz, and which presents the appearance of the lung of a foetus 
which has never breathed, is considered by the authors to be a termination 
of pneumonia, or, as it were, a chronic form of it, it being sometimes 
possible to trace the transformation by which the pulmonary parenchyma 
passes from the first degree of inflammation to it. Indeed, with the ex- 
ception of this lesion, they assert that they have never met with any which 
could be regarded as indicative of chronic pneumonia, except in tuber- 
culous cases, which we shall have occasion to notice hereafter. 

As regards the prognosis of this disease, the authors are inclined to 
modify their former opinion, they having stated with MM. Gerhard and 
Rufz, that in general pneumonia, occurring in children between the ages 
of 6 and 15, in the midst of good health, terminated in a cure. This they 
now believe to be too broad a statement, and they deem that they will 
better express the results of their observations in the following words. 

"Lobar pneumonia, occurring in children between 6 and 15, in the enjoyment 
of previous good health, when it occupies only one lung, and is complicated by 
no secondary affection, gets well in the great majority of cases." Vol. i. p. 107. 

The gravity of complicated pneumonia depends upon the nature of the 
secondary afl'ections. Amon^? the most fatal is rubeola, which, in the 
great majority of cases, provokes the reappearance of the inflammation, 
and causes it to assume a form always very serious, (double generalized 
pneumonia). 



124 Review. [July 

The treatment seems to be wisely directed, except as to the very free 
use of tartar emetic. The authors, indeed, advise caution in administering 
it to very young children, because of the danger of exciting vomiting and 
diarrhoea. These evils are certainly very serious, and should be carefully 
guarded against; but there is another, which is not less alarming, but to 
which the authors do not even allude; we mean the sudden and sometimes 
fatal prostration which it often causes in very young children, and which 
should always make us watchful of the cases under its use. Of calomel, 
too, in this disease, they speak doubtingly, at which we are somewhat 
astonished, its effects being here and in England so well known and so 
highly appreciated, as to make it, either alone or combined with opium, 
to be looked upon as the sheet-anchor in our treatment. Upon the whole, 
however, we do not hesitate to say that we have never met with a more 
able or a more complete exposition of the history of this disease, under all 
its forms, and under every aspect, than that which is contained in this 
chapter. Not a single point is overlooked, and yet the facts are grouped 
together so clearly, and at the same time so naturally, that they cannot fail 
to impress the reader with the conviction of the accuracy and truthfulness 
of the descriptions presented 

As a part of the history of bronchitis and pneumonia, a chapter follows 
on emphysema. This, " in a great majority of cases, is a mechanical and 
almost necessary consequence" of these affections, though almost any dis- 
ease which causes a considerable acceleration of the respiration may pro- 
duce the same condition. In children the dilatation of the vesicles is almost 
always an acute affection, differing in this from that of adults, with the 
exception, however, of rachitic individuals, in whom it occurs from pres- 
sure exerted by the ribs, and in whom alone it is chronic, and resembles, 
in its extreme dyspncea, that which is met with in adult asthmatic patients. 
In children the sound on percussion remains normal, the appearance of the 
chest natural, and the respiration is remarkably exaggerated. Hence there 
is much difficulty in ascertaining the presence of emphysema, although it 
may be suspected in all cases where the chest is deformed by rachitis, or 
where an acute affection of the lungs, prolonged for some days, has caused 
great respiratory efforts. 

"The causes may be summed up, in a forced distension of the pulmonary 
cells, in consequence of the impossibility of the air penetrating into other parts 
of the organ, or in an obstacle to inspiration, situated either in the bronchi or at 
some higher portion of the respiratory tubes. * * To these causes must be added 
acceleration of the respiratory movements, the intensity of the emphysema being 
in direct proportion to that of the oppression." 

In their account of pleuritis, which occupies the next chapter, the 
authors exclude all cases which were complicated with tubercles, referring 
the reader to the third volume of the work for a description of this and 
other forms of tuberculous disease. 

Without dwelling too long on this disease, we would direct attention to 
the following interesting remarks upon the modifications of the stethoscopic 
signs in cases of pneumonia complicated with pleurisy. 

"We lay it down as a principle," say the authors, "that, when a pleuritic 
affection takes place in a child labouring under an hepatization of the posterior 
part of the lung, all the anormal sounds which were perceived at the level of the 
diseased point are considerably exaggerated, and the sonorousness disappears. 
We mentioned just now that this curious phenomenon does not occur in all 



1844.] Rilliet and Barthez on the Diseases of Children. 12S 

cases. The necessary condition for its production is, that the hepatization is 
sufficiently extensive and profound to prevent the lung from collapsing. Thus 
it may be inferred that if an entire absence of respiratory murmur succeeds the 
symptoms of a well-determined pneumonia, the hepatization was of slight 
extent, and but little profound ; whilst, on the other hand, if the souffle, the 
resonance of the voice, and the dulness are suddenly increased, the pneumonia, 
to which the pleuritic effusion has just been added, occupies a large extent both 
in depth and surface." Vol. i. p. 153. 

The treatment of pleurisy is conducted by the authors with much pru- 
dence. In the acute secondary attacks, and in the chronic form, they 
recommend, after the German practitioners, from whom they liave adopted 
this practice, the use of calomel and digitalis. But at the same time, almost 
repenting the sanction they thus give, they advise extreme caution in the 
use of this "energetic medicine," calomel, especially in debilitated consti- 
tutions, and when it manifests a tendency to act too freely upon the bowels, 
never apparently dreaming of the possibility of combining it with opium 
to counteract such effects. Such is their general method of speaking of 
calomel, and we cannot help remarking that this bugbear of French thera- 
peutics pursues the authors throughout their work. It is true that the use 
of this medicine is very often recommended by practitioners when it 
might well be dispensed with, and that injurious efTects occur from the 
indiscriminate employment of it in all sorts of constitutions; but it cannot 
be denied that the prejudices due to this cause would deprive us of a very 
valuable remedy when properly directed, and would materially diminish 
our powers of successfully combating disease. 

The authors have little confidence in blisters in the acute forms of 
pleurisy, and have no experience with them in chronic cases, though they 
think it may be useful to cover the affected side with a large diachylon 
plaster, to protect it from the action of cold, and to produce a slight cuta- 
neous irritation. Of the operation of empyema they entertain a favourable 
opinion, and advise it where other remedies have failed to produce relief, 
as chronic pleurisy, independent of tuberculous disease, is not very rare in 
children, and, therefore, the operation ofiers a pretty good chance of relief 
and cure. 

Pneumothorax in children, as far as the authors have observed, arises 
solely from a perforation of the lung, allowing the escape of air into the 
cavity of the pleura; they have never met with a case of which the origin 
could be traced to gaseous exhalation there. Its prognosis is more favour- 
able in the child than in the adult, because children will bear a greater 
degree of dyspnoea, because cases have been prolonged for one or more 
months, because abscess of the lungs, one of its causes, is not necessa- 
rily fatal, and because cases of cure have been reported. MM. R. and B. 
have themselves witnessed two cases which recovered without any medical 
treatment, and M. Constant reports one cured by opiates. Seven cases of 
this affection are reported by the authors, all of which followed pneumonia; 
six of them were fatal, and one was cured. The perforation in those ana- 
lyzed was very small, and led into abscesses precisely similar to those 
described under the head of pneumonia. Two detailed cases, one of 
which was fatal and the other recovered, are related at the end of this 
chapter. 

In continuation of their account of the inflammation of the organs 
within the chest, the authors next consider that of the heart and of its 

11* 



126 Review. [July 

internal and external membranes. In looking over the recent works of 
Stewart and Condie on the diseases of children, we find no mention made 
of the occurrence of any of these cardiac affections; nor is this to be 
wondered at; for with the more extensive opportunities enjoyed in the 
European hospitals for pathological researches, they have failed to attract 
attention until within a very recent period. 

Of pericarditis, which is " a rare and almost always secondary affection 
in childhood," 24 cases have been collected, and form the basis of the 
chapter on that disease. It is almost exclusively met with in children 
over six years of age, as a complication in the course of some other dis- 
ease, especially rheumatism and scarlatina, and may be distinguished by an 
*' obscurity in the beating of the heart, dulness on percussion, prominence 
of the precordial region, a rubbing sound (bruit de frottement) or a 
bellows murmur, during the first sound of the heart." It is not considered 
a very grave affection of children, less so when partial and occurring with 
rheumatism, than when general. The grounds of this prognosis "are, 
1st, the frequency of milky spots, and of limited adherences, traces of 
cured partial pericarditis; 2d, the number of cases resulting in cure, col- 
lected by the authors, and the fact that in most of the children which died, 
death chiefly resulted from the diseases which had preceded the pericar- 
ditis." The treatment of this disease should consist in the use of anti- 
phlogistics, especially blood-letting, and of digitalis and calomel, with 
nitrate of potassa. 

Endocarditis and hypertrophy of the heart are rare diseases among 
children, and have never before been studied at this early period of life, 
except in a few isolated cases. MM. Rilliet and Barihez have collected 
and analyzed 16 cases, of which 3 of endocarditis were cured. Though 
presenting many interesting particulars in their history, they are not suffi- 
ciently numerous, and they differ too much in detail to allow the au- 
thors to give a general description of them. Evidences of inflammation 
of the internal membrane of the heart, similar to those observed in adults, 
but less advanced in their stage, were encountered in these cases. They 
consisted in bright inflammatory redness, adherences, insufficiency of the 
valves, simple, cartilaginous, and osseous thickening and vegelations, gene- 
rally coinciding with lesions of the heart, though not necessarily so. Dila- 
tation and hypertrophy were nearly equally frequent, though the authors 
are of opinion, judging from the small number of cases, " that children are 
much more disposed to dilatation than to hypertrophy of the heart ; and 
this," they say, " is by no means astonishing, when we recollect that the 
feebleness and atony of the organ are the origin or consequence of a great 
number of the diseases of children." Vol. i. p. 221. 

Several cases of clots found in the heart, and some, in particular, which 
were found in a state of suppuration in the centre one observed by the 
authors, and two by M. Marechal, are detailed, and a table is given of all 
the lesions of the heart in 12 cases of cardiac disease analyzed, so as to 
show their frequency and character. These affections of the heart are not 
liable to be confounded with any other than pericarditis, from which they 
may generally be distinguished by the existence of a slight bellows sound 
during the first sound of the heart, without any unusual extent of dulness 
on percussion, with strong pulsations felt close under the hand, though dull 
in sound. No particular treatment is laid down for these cases. 

As regards the persistence of the foramen ovale with hypertrophy of the 



1844.] Eilliet and Barthez on the Diseases of Children, 127 

heart, the authors mention their inability to speak of it, it being a congeni- 
tal affection, and one of which they have met with no example. 

From the inflammatory affections of the chest the authors proceed, in 
the order they marked out, to those of the nose, mouth and neck, com- 
mencing with coryza. In its usual form this is a simple disease, and is 
too well known to require careful description ; but there is a purulent and 
pseudo-membranous form, which has never been described, but which the 
authors have met with occasionally, and find examples of recorded in 
the works of M. Bretonneau and others. It coincided almost always with 
a primitive or secondary pseudo-membranous angina, showing its analogy 
with it. It is a very serious afl^ection, every child which presented it 
having died " under the influence of the first affection as well as of the 
coryza." Indeed, it seems to us to be nothing more than an extension 
of the diphtheritic afl?"ection of the mucous membrane of the nose, either 
having its commencement there, or attacking it secondarily. 

A short chapter on pellicular or ulcero-membranous stomatitis follows. 
It is a disease distinct from gangrene of the mouth, and of which " the 
essential and pathognomonic symptoms are more or less deep ulcerations 
and false membranes covering them;" it is not of itself a very serious 
aflfection, yielding easily to appropriate treatment, which consists in re- 
moving the child from the improper hygienic conditions which are gene- 
rally its cause, and in making use of emollient gargles and washes of the 
solution of the chloride of lime, with alteratives and tonics internally. 

Pharyngitis or angina, comprehending inflammation of the velum palati, 
amygdalae and pharynx, which are generally found united in nature and of 
which the separation in description, in children at least, would lead to no 
practical advantages, may be either erythematous or pseudo-membranous in 
its anatomical character. The erythematous form is well known and well 
described here, but it is to the pseudo-membranous form that chief atten- 
tion is directed, because it is peculiar to children. It may be primitive, 
corresponding with the gangrenous angina of authors and the diphtheritis 
of M. Bretonneau, or secondary, occurring most frequently in the course 
of eruptive fevers, as witnessed in scarlatinous angina, which may be con- 
sidered a type of these secondary forms. In both of these, the pseudo-mem- 
branous exudation takes place ; in the former, seated generally upon a 
mucous membrane, which preserves its polish and consistence, but some- 
times is studded with ecchymotic spots, and, as the authors observe, occa- 
sionally presents ulcerations; these last, however, are exceptional cases; 
in the latter, the mucous membrane is intensely red, rough, thickened and 
softened and the amygdalae are swollen, soft and infiltrated with pus; with 
deep-seated ulcerations at times. MM. Rilliet and Barthez agree with M. 
Bretonneau in believing that those who have spoken of the gangrenous 
tendency of the primitive form of this disease, have fallen into the error of 
mistaking for sphacelus both of the false membranes and posterior fauces, 
what are in fact, putrefied false membranes, continuous with the membra- 
nous cylinders lining the larynx, &c., the mucous membrane underneath 
being entirely free from any thing like sphacelus. New facts, indeed, 
show that gangrene of the pharynx does occasionally occur, sometimes spo- 
radically, at others epidemically, but as the authors have proved in a me- 
moir on the subject, in both cases it was entirely distinct both in its march 
and symptoms from pseudo-membranous angina, though both may un- 
questionably attack simultaneously the same individual. 



128 Review. [July 

As a general rule, except where the epidemic assumes a typhoid cha- 
racter, requiring a tonic and stimulant medication, the treatment should be 
moderately antiphlogistic, with an especial attention to topical remedies, 
consisting in the application of caustics, as hydrochloric acid, nitrate of 
silver, chloride of lime, &c., directly upon the affected parts; we should 
combine therewith the use of emetics, and in epidemics, a constitutional 
treatment of calomel or the sulphuret of potassa. There is an objection to 
bleedings, when a tendency to haemorrhage or cutaneous diphtheritis exists; 
the cutaneous lesions caused by the bites of leeches, the section of a vein 
or a scarification may become the seat of a fatal haemorrhage, or may give 
rise to formidable ulcerations which in these cases sometimes invade a 
large extent of surface. The possibility of such an accident should also 
make us reject the use of blisters entirely in pseudo-membranous angina. 

Laryngitis, so terrible and fatal in some of its modes of attack and about 
which so much has been written, is described in the pages before us under 
five distinct forms: 1, the pseudo-membranous, either primitive, constitut- 
ing true croup, or secondary ; 2, spasmodic, or the asthma of Millar, stri- 
dulous croup, in which the inflammatory element is combined with a ner- 
vous one; 3, acute erythematous and ulcerous; 4th, chronic, and 5th, 
submucous, or oedema glottidis. 

Of these, the most fearful and the most important in its consequences, is 
without any question, pseudo-membranous laryngitis or croup. The only 
positive diagnostic symptom of this form is the rejection of false mem- 
branes. Unfortunately, however, this does not take place in every instance, 
the authors not having noticed it in more than one-third of the cases which 
have passed under their observation, and when it does, not until the. disease 
is already confirmed, often the day before, or that on which, death occurs; 
besides, it must coincide with other symptoms of the disease, and the false 
membranes must present the characteristic marks assigned to them, namely, 
a whitish yellow colour, the free surface often covered with a layer of 
puriform mucus, while that next to the mucous membrane is smooth, 
sometimes marked with longitudinal striae, corresponding with analogous 
lines in the trachea, caused probably by the contraction of its fibres. 

The authors agree in opinion with many recent writers, that a second 
attack of true croup never occurs. They state that they cannot discover a 
single clear example of its recurrence in the records of science, those so 
entitled being evidently cases of spasmodic laryngitis. 

"There are some, however, in which we find that children who had expe- 
rienced several attacks of croup, finally died of pseudo-membranous laryngitis: 
but this only proves that false croup does not protect from attacks of true croup. 
Indeed, there is a very simple cause for the absence of second attacks, in the 
fact that the first is almost always fatal." Vol. i. p. 343. 

The treatment by means of calomel pushed to the utmost extent, and by 
emetics is recommended as that which will be found the most useful ; while 
great caution is advised in having recourse to blood-letting, this remedy 
being restricted to those cases in " which the child is vigorous, the disease 
sporadic and at the commencement the febrile reaction intense, and the fits 
of suffocation well marked." In all cases it should be moderate. These 
fits of suflTocation, by the way, are not so constant as is generally asserted 
to be the case, they having been wanting in one-third of the cases ob- 
served by the authors, and M. Hache. M. Maunoir of Geneva has recently 



1844.] Rilliet and Barthez on the Diseases of Children. 129 

met with some success from the employment of the sulphuret of potassa, 
and again recommends it to the profession. 

The most important matter relative to the treatment is contained in a 
memoir by M. Trousseau, which was placed by him in the hands of the 
authors for publication, and which is here given entire. It contains a sum- 
mary of M. T.'s opinions and experience relative to the operation of tra- 
cheotomy, with a simple exposition of the reasons why he prefers this to 
that of laryngotomy. He recommends its performance, as soon as it is 
clearly ascertained that there are false membranes in the larynx, as the 
chances of success are thus much augmented, because, the false membra- 
nous covering has not yet had time to descend into the trachea and bron- 
chial tubes and, by preventing the proper changes in the blood from the con- 
tact of the air, has not yet given rise to pulmonary engorgement or cerebral 
congestion, and because the topical treatment, consisting in caustic appli- 
cations mtroduced through the opening into the trachea, of which he always 
recommends the adoption, and which he never fails to put in use himself, 
may be earlier employed to prevent the extension downwards of the 
disease, and will in all probability prove more beneficial. The mode of 
performing the operation, the necessary precautions to be observed, and 
the treatment afterwards to be instituted are carefully and ably exposed, 
and the paper is concluded by a series of statements, exhibiting the prog- 
nostic signs of almost every possible case which may present itself. (See 
Summary department of Surgery in this number.) 

The second form, for which the authors prefer the name of spasmodic 
laryngitis, as "indicating the inflammatory and nervous elements which 
constitute the disease," has only recently attracted attention in France, 
though cases of it are recorded by Jurine and are found scattered in the 
journals. It had long been confounded with true croup, from which our 
authors clearly distinguish it — their method of diagnosis was presented in 
a previous number of this Journal by the reviewer of Dr. Condie's recent 
valuable work on the Diseases of Children — and state, as before noticed, that 
they believe that the cases of recurrence of croup, cited by different authors, 
belong in fact to this form of disease : they even consider it very rare to 
find this recurring within shorter periods than from six months to one or 
two years, of course not including relapses. It is most frequently observed, 
say MM. R. and B., between three and eight years of age, which is later 
than in the cases of Guersant, who says it is most common between one 
and seven, and which differs entirely from the statements of our own au- 
thors, who consider it almost peculiar to the period of first dentition, or 
from four months to two or three years. Even when uncomplicated, it 
may be a serious affection : we should never, therefore, give an entirely 
favourable opinion of it, until positive marks of improvement are manifest, 
and we should immediately treat it actively and without intermission by 
warm baths, emetics, sometimes by blood-letting from the arm or by leeches 
and revulsives externally. 

Erythematous and ulcerous laryngitis, which are only degrees of one 
and the same disease, present very similar characters, differing in fact only 
in intensity, the former almost always recovering or passing into a chronic 
state, the latter, being an acute, serious primitive attack, following a rapid 
course, being a little more favourable in its prognosis than croup, and re- 
quiring much the same treatment. The erythematous form was, in every 



130 Review. [July 

instance observed by the authors, a secondary attack, manifesting itself 
most frequently in rubeola, variola, scarlatina, &Lc. 

Chronic laryngitis, independent of tuberculous disease, is a very rare 
affection among children, the authors having met with it in but two cases, 
both girls about 13 years of age. Submucous laryngitis, or oedema glotti- 
dis is also very rare, though cases of thickening of the mucous membrane 
covering the vocal ligaments and the epiglottis are occasionally observed. 
Two cases only have been collected by the authors, and are reported in the 
chapter under consideration, where we find allusion to two others which 
have been published by Guilbert, which are very incomplete. 

In continuation of the subject of inflammation, we are now brought to 
the consideration of the phlegmasiae of the organs within the abdomen. 
The preliminary chapter contains a general account of the healthy and 
cadaveric appearances, and the pathological lesions, common to the whole 
gastro-intestinal tube, the reader being referred to subsequent chapters for 
a more detailed description of those peculiar to each portion of it. Atten- 
tion is directed to the contracted state of the stomach sometimes met with, 
it being so diminished in size as to be "scarcely larger in diameter than 
the arch of the colon." This condition is solely the result of muscular 
contraction, as is proved by the fact that upon the section of its muscular 
fibres the natural capacity of the stomach may be restored. It may be 
produced by disease, as by acute peritonitis, or in consequence of low diet 
continued for a long period whether by the orders of the physician or by 
the carelessness and malevolence of the attendants, or it may be a mere 
cadaveric contraction, yielding, however, to the general relaxation of com- 
mencing decomposition. This last view appears to be sustained by the 
fact that the authors have never met with this contraction in children, who 
have been some time dead and who present the marks of advanced putre- 
faction. 

Referring to that appearance of the mucous membrane, consisting in the 
presence of small black points, evidently seated in the follicles, and some- 
times so numerous as to give the mucous membrane a blackish gray, or 
almost black colour, MM. Rilliet and Barthez, without attempting to solve 
the question, whether it is the result of inflammation or congestion, say, 
"we have found that this deposit of black matter is attended with no de- 
rangement of the digestive functions, and perhaps it should be considered 
similar to that which takes place in the pulmonary parenchyma and in the 
bronchial glands." Vol. i. p. 437. 

Simple softening of the mucous membrane of the stomach, and especially 
of that of the great cul-de-sac, may occur as a diseased condition or as a 
cadaveric appearance; "but," say the authors, "taking into consideration 
the circumstances of temperature and of putrefaction under which we most 
generally meet with it, we are of opinion that the softening found on an 
examination made 24 or 48 hours after death, is more usually cadaveric 
than morbid." An opposite rule holds good in reference to softening of the 
intestinal mucous membrane; that is to say, its simple softening is much 
more often morbid than cadaveric. If there are evident signs of putrefac- 
tion, we may, without being certain of it, believe that the softening is ca- 
daveric; otherwise it is morbid, especially if the intestines contain litde or 
no liquid matters ; and it is under these circumstances, that it is most fre- 
quently observed. 

These and other natural and cadaveric appearances are separately studied, 



i 



1844.] Rilliet and Barthez on the Diseases of Children. 131 

and the chapter concludes with an admirable and well-digested summary 
of the anatomical characteristics of inflammation of the gastro-intestinal 
mucous membrane. Among the lesions described, are what the authors 
call pustules. This pustular inflammation has been but rarely met with, 
and always coincided with the administration of tartar emetic. It consists 
in a multitude of little elevations upon the internal surface of the stomach 
and small intestines, some scarcely prominent, others about half a line in 
height, from about half a line to a line and a half in diameter, generally 
presenting a central depression, and formed of a soft yellow matter, inti- 
mately confounded with the mucous membrane, and surrounded by a red 
areola of small extent. Sometimes they are larger and undoubtedly puru- 
lent in character, and are in that case found seated in the plates of Peyer's 
glands. This suppuration is, as it were, combined with the mucous mem- 
brane, and the pustule is not formed by the elevation of this membrane or 
of an epithelium by a purulent drop. 

Finding no important symptomatic difl^erences between inflammation 
and softening of the mucous membrane of the stomach, MM. Rilliet and 
Barthez consider these affections at the same time, and under the same 
head. While they admit that gastritis is more frequently and easily pro- 
duced in children by an irritating cause, than is generally admitted at pre- 
sent by the strong opponents of the doctrines of Broussais, they declare 
their belief, that "it should not occupy an important place in the nosology 
of childhood," and that if they are in apparent contradiction to many authors, 
in aflirming that softening of the stomach is only "a secondary lesion and 
not a primitive affection, controlling the organism, revealing itself by pecu- 
liar symptoms, and following a certain march," the reason must be looked 
for in the age of the children, who have passed under their inspection, for, 
according to all authors, except a few of the German writers, the gelatini- 
form softening, so much spoken of, of late, manifests itself chiefly between 
the period of birth and two years, attacking children of enfeebled constitu- 
tion, or labouring under other diseases, and being, under these circum- 
stances, a serious aflection. While children of all ages are equally liable 
to gastritis, softening is much more frequent under than over six years of 
age, and among girls and cachectic children, than among boys and thestrong 
and robust. 

One of the most common causes of both these forms was, we are told, 
the employment of energetic medication, directed upon the gastro-intestinal 
mucous membrane, and particularly of the tartar emetic potion, repeated 
during several successive days. Two-thirds of the cases of gastritis and 
some of the softenings followed the use of these medicines, but in almost 
all these, the disease for which they were prescribed, was a secondary 
aflection, the same consequences having scarcely ever been observed, when 
they were administered in a primitive disease. When the inflammation 
coincided with the administration of large doses of antimonials, " more or 
less copious and repeated bilious vomitings were almost constanfly observed, 
while in the very small number of cases in which there was stomachic 
tolerance with gastritis, there was generally a development of antimonial 
pustules (as above mentioned) in the intestines. . . Vomiting, on the other 
hand, when the gastritis was spontaneous, was almost always absent, espe- 
cially if there was enteritis present at the same time. . . In cases of soft- 
ening, vomiting is less frequent than in gastritis after the administration 
of tartar emetic, but more frequent, when the softening is not caused by 



132 Review, [July 

this medicine ; at the same time, vomiting more frequently accompanies 
softening coinciding with the use of tartar emetic, than spontaneous cases." 
P. 462. 

From these facts, MM. R. and B. conclude that the opinion advanced 
by authors, that softening of the stomach is accompanied by constant, fre- 
quent and very copious vomiting, the children being unable to retain a 
single drop of liquid within the stomach, is most generally erroneous even 
in cases of gelatiniform softening. 

Inflammation and softening of the intestines, whether erythematous, 
pseudo-membranous or follicular, are presented at length in the next chap- 
ter. The latter form, especially when occupying Peyer's glands is most 
carefully examined and studied, and the reader is cautioned against mis- 
taking it for typhoid fever, to which it bears a close analogy, and from 
which, especially in very young children, it differs only in degree, they 
being often confounded together at that time of life and only gradually sepa- 
rating themselves with age. It is generally met with in the eruptive fevers, 
which so closely approach typhoid fever, and thus constitutes another 
point of analogy between these fevers and it. 

The inflammatory afl'ections of the large intestines are among the most 
destructive and frequent that are encountered in children; so much so, 
that MM. R. and B. state, comprehending in their calculation tuberculous 
cases, that one-half of the children which died, exhibited a more or less 
serious lesion of the large intestines; and when it is recollected, that this 
is especially the case with the youngest children, it will be seen that it is 
rare that a child between two and five years of age, dies without a colitis or 
softening of the larger intestines. As regards the symptoms, diarrhoea, 
which is " one of the most frequent phenomena in the pathology of child- 
hood," is present as a general rule, in all forms of intestinal inflammation, 
the exceptions occurring only in slight cases. " It was absent in about 
one in twelve cases of inflammation or softening, whilst, on the other hand, 
of every twelve children who laboured under diarrhoea, giving ground for 
the suspicion of the existence of colitis, one presented a perfectly healthy 
condition of the intestinal canal. This statement is based upon about 300 
post-mortem examinations, including tuberculous cases." Vol. i. 491. 

Reasoning a priori^ we might expect constantly to meet with gargouiU 
lement in these cases. The fact, however, is not so, and although the 
same circumstances which appear to give rise to it in typhoid fever, of 
which it is so characteristic, exist in these cases, it is, nevertheless, an ex- 
ceedingly rare symptom, the authors having ascertained its existence " only 
four times out of several hundred cases of affection of the intestinal tube, 
not typhoid, among which were many cases of follicular inflammation." 

These diseases are studied under four heads, acute normal, typhoid, 
dysenteric and chronic inflammation of the large intestines. The first is 
a mild, easily managed afi'ection, when primitive, but capable of causing 
more serious consequences when occurring as a complication of some other 
acute disease, and therefore requiring strict attention on the part of the 
practitioner. It may complicate most of the diseases of childhood, and 
especially typhoid and eruptive fevers, among which rubeola is in this 
respect most prominent. The treatment must in such cases be directed 
against the primitive aflfection. 

The typhoid form, to which the authors first directed attention, as being 
peculiar to children, resembles true typhoid fever in so many respects, 



1844.] Rilliet and Barthez on the Diseases of Children, 133 

though differing in some of its pathological and symptomatic phenomena, 
that it can hardly be looked upon, we think, as any thing else than a modi- 
fication of this disease, dependent upon the age of the child, showing, as 
the authors remark, a tendency in typhoid fever and enteritis to be con- 
founded together during childhood, and to separate at a later period of life, 
becoming then distinct diseases. 

Of the dysenteric form of entero-colitis the experience of the authors is 
too limited to enable them to present any important or valuable considera- 
tions: they therefore terminate this chapter with an account of the chronic 
or cachectic inflammation of the intestines. This may be guspected to 
exist, almost without fear of mistake, " whenever, in the absence of tuber- 
cular disease, a child is observed to fall away gradually, with a constant or 
rarely intermitting diarrhoea, if at the same time, the abdomen is more than 
usually flaccid and soft, or tender or painful; if the appetite is preserved, 
and if the thoracic organs, the liver and the spleen are in a healthy condi- 
tion," of which facts we may assure ourselves by direct exploration. Vol. 
i. p. 536. 

This is a very serious form of disease, and causes the death of a large 
number of children. The foundation of it is apt to be laid during the 
period of first dentition and the substitution of a new diet after weaning. 
The child should, therefore, be carefully watched at this time, its nourish- 
ment should consist of such food only as is found perfecdy to agree with 
it, and it should enjoy the benefits of fresh air, cleanliness, exercise, &c. 
Indeed, this disease is within the control of properly directed hygienic 
treatment and of medicine, the children dying rather of the complications, 
of which the occurrence is favoured by their debilitated condition, than of 
the disease itself. Among the fatal complications, secondary pneumonia, 
is, we are told, unquestionably the most prominent, it being ascribable to 
the stasis of the blood in the lower parts of the lungs which is favoured by 
the cachectic and deteriorated state of these and other organs. 

Important as it is in a scientific point of view, and as affording a nucleus 
around which to group the interesting facts which constantly fall under 
notice, and as the true method of establishing a fixedness in the views and 
opinions which are emitted relative to the diseases of the bowels, that the 
anatomical form should be carefully and accurately described and, as far as 
possible, traced in its connection with the symptoms generally attendant 
upon such morbid condition, so as to avoid the constant repetition met 
with in our systematic treatise, still, it must be confessed, as the authors 
themselves are compelled to admit, that the gravity of the symptoms and 
the extent and character of the lesions met with in the intestinal canal, 
are very far from corresponding, and that in fact the symptoms give the 
true indications for treatment in the present state of our knowledge of the 
affections of the bowels. 

Acute peritonitis is, according to the observation of MM. Rilliet and 
Barthez, the least frequent of all the serous inflammations, except arach- 
nitis. Of course, it must be recollected, that the children upon whom 
these remarks have been made, are far removed from the period of birth, 
(when this disease is said to be the cause of many deaths,) and that reference 
is made to those cases which occur apart from tubercles either in the peri- 
toneum or in other parts of the body — the consideration of cases in which 
these are present being reserved to a subsequent portion of the work. 
The authors have never met with a case of chronic non-tuberculous perito- 
No. XV.— July, 1844. 12 



134 Review. [July 

nitis. Among the symptoms enumerated as characterizing this inflamma- 
tion, are pain, tension and tympanitis of the abdomen, restlessness, fever, 
and a peculiar distressed expression of the countenance; but the authors 
have not met with vomiting and constipation so constantly as they have 
been said to occur. In effect, of the twelve cases, of which the histories 
are recorded by them, vomiting was observed in but two at the commence- 
ment, and in one about the 11th or 12th day, while constipation occurred 
in but two cases, in one of which the inflammation was consequent upon 
scarlatina, and in the other, upon perforation of the intestines during an 
attack of typhoid fever, when the diarrhoea which had previously existed 
and the urinary discharges were suppressed. Diarrhoea, on the other 
hand, existed in all the other cases from the commencement to the end of 
the disease, when death resulted, or for several days, v/hen recovery took 
place : those which died, however, presented a slight softening of the mu- 
cous membrane of the large intestines. The treatment of this affection, of 
which the prognosis is always very grave, except perhaps when the inflam- 
mation is circumscribed, consists in an early resort to decided antiphlogistic 
means, when the age and constitution will admit of it, and in the use of 
mercurials and opium with warm baths, warm topical applications and 
acidulated drinks. 

" Hepatitis is a rare disease among children;" we find no account of it 
in the recent works on the diseases of children, which have been published 
in this country, nor is any to be met with among the European writers, 
which corresponds with the description here given of it. The authors 
have collected but six cases of it, of which one was fatal: they were all 
primitive except this last, which occurred in a consumptive child, who 
died after presenting symptoms precisely analogous to those observed in 
the other five. The description presented in this chapter is founded solely 
upon the authors' own observations, they having been unable to discover 
any cases reported in the periodical publications or elsewhere. The disease 
commenced in all with a marked febrile movement, thirst and anorexia; 
an icteric tint was soon observed, at first limited to the conjunctivae, and 
slight, soon extending over the skin, and of a more decided colour ; the 
liver now increased in volume, passed beyond the edges of the ribs, ex- 
tended into the epigastrium, and at the same time rose in the hypochon- 
drium, causing the dulness on percussion to extend up higher; generally 
indolent, the tumour was easily circumscribed when the abdomen was soft 
and relaxed, but with more diffic\iliy when this was tender; at the same 
time the urine changed in appearance, becomitig beer-coloured, while the 
stools were natural, rare, or frequent, colourless. After a longer or shorter 
period the febrile symptoms disappeared, the tumefaction of the liver 
gradually diminished, the icteric colour gradually disappeared, the urine 
and stools became natural, and after twenty or thirty days all the morbid 
symptoms were removed, the acute symptoms having usually ceased some 
time before. 

In the fatal case the liver, after death, was heavy and enlarged, smooth 
and regular on its surface, which was of a bilious yellow colour, — of a 
natural consistence, presenting, upon cutting into the larger lobe, a granitic 
appearance, or a mixture of bright red spots with an equal amount of yel- 
low substance. The left lobe was free from these appearances, and the gall- 
bladder contained a glutinous brownish bile. When primitive this is not 
a serious disease, the liver readily resuming its natural size, and, therefore, 



1844.] Rilliet and Barthez on the Diseases of Children. 135 

not passing probably beyond the first degree of inflammation. Other 
writers, as Henke and Burns, as noticed by the authors, have met with a 
more severe form of inflammation of the liver, complicated with cerebral 
symptoms, and terminating occasionally by abscess, as recorded by Burns. 
The treatment recommended by MM. Rilliet and Barthez, is to diminish 
the febrile movement, to resolve the tumefaction, and to promote the 
normal secretion of the bile by means of antiphlogistic remedies, of 
calomel and mercurial frictions, followed by the use of a combination of 
aloes, rhubarb, and soap. 

In their account of the inflammatory affections of the kidneys, the authors 
have followed the classification of M. Rayer, and have arranged all the 
cases of disease of these organs, which have passed under their observa- 
tion, under the heads of simple and albuminous nephritis, calculous 
nephritis and pyelitis, hyperaemia and anaemia of the kidneys, referring 
the reader to a subsequent part of the work for an account of renal hemor- 
rhage. 

"A very remarkable difference," v/e are told by MM. R. and B., "exists 
between the albuminous nephritis of adults, and that which they have been 
enabled to observe in children, a difference which renders difficult the anatomical 
distinction between simple and albuminous nephritis. It is, that the disease 
rarely produces the granulations of Bright, and that, in the generality of cases, 
it only passes to the third degree. So true is this, that of eleven children who 
presented, during life, the symptoms of albuminous nephritis, viz., a more or 
less extensive anasarca, with albuminous urine during a longer or shorter period, 
four only offered the third degree, two the second, and four the first, while, in 
one instance, the kidneys were putrefied. In a twelfth case they ascertained, at 
the autopsy, the existence of granulations, but the urine had not been examined 
during life, and furnished no albumen after death. On the other hand, in the 
few cases of simple nephritis they have seen ihey never met with suppuration, 
either diffused, or in scattered points, or collected in abscesses. I'hey have, 
therefore, only been able to compare the nephritic attacks in children in their 
first stages, and sometimes under the simple chronic form. 

"Now, according to the description of M. Rayer, the two kinds of nephritis 
are with difficulty distinguished at their commencement; the only difference 
which he points out being in the consistence, which is increased in one and 
diminished in the other. In simple nephritis the increase of consistence has 
appeared to the authors to be more marked in children than in adults. On the 
other hand they have noted, in the three first degrees of albuminous nephritis 
a marked diminution of consistence of the cortical substances. . . . Thus, 
in respect to their anatomical relations, these two kinds of nephritis much re- 
semble each other. If it is added that during life the difference is not always 
more marked, it must be agreed that in infancy the two affections are but little 
separated from each other. In effect, the same is observed, at this period of life, 
with regard to several other diseases, which in adult age have little relation with 
each other." Vol. i. p. 585-6. 

As regards the anatomical appearances of these two forms of nephritis, 
in the simple, we find a morbid red colouring of the kidneys with increased 
volume and consistence, but without suppuration; while, at a more ad- 
vanced stage, and in a chronic case, " tw^o different lesions are met with ; 
a partial or general discoloration, with increased volume and hardness 
of the kidneys, and irregularity of the surface, or a smaller volume, with 
condensation of the tissue and a deepened colour. In the albuminous, with 
increased volume there is morbid colouring and softening of the cortical 
substance ; at a later stage the same tissue is marbled with yellowish spots 



136 Review, [July 

of varying size, which at a third stage invade the whole of the cortical, and 
sometimes even the tubular substance. It does not attain the fourth stage 
as often as in the adult." Vol. i. p. 591. 

Anasarca, which is the prominent, as well as the first S3'raptom noticed, 
for in no case was the urine examined before this appeared, is liable to 
oscillate and even disappear, leading to the hope of a cure having been 
effected. It should not inspire too much confidence, for "the cessation of 
albuminuria alone is a positive symptom of the restoration of health." 
This last symptom alone distinguishes the two forms of diseases, and is 
therefore of much consequence. It is from the complications of the disease 
that most danger arises ; the most important of these are inflammation of 
those organs which are subject to dropsical effusions; they occur most 
frequently in the serous membranes and in the lungs, and are attended 
with more or less copious serous effusion. "All the children which died 
presented one or more serious complications, and the only cases of simple 
albuminous nephritis the authors met with, were in children which re- 
covered. The absence of these complications, however, is rare, and if a 
cure is obtained, it is generally in spite of one or more intercurrent affec- 
tions." Vol. i. p. 604. 

Both forms are serious diseases. The simple was only recognized after 
death; the albuminous, however, has been cured by them in one half the 
cases, of which the character was determined during life. " Two of those 
cured died at a subsequent period, and upon examination it was ascertained 
that the cure was positive, and that the kidneys were in a normal condi- 
tion. . . But by a singular coincidence chronic nephritis is found to have 
been more frequently cured than the acute form, which generally carries 
off the patients rapidly, while the former is more amenable to treatment." 
Vol. i. p. 605. 

Secondary albuminous nephritis is chiefly met with after eruptive and in- 
termittent fevers. After scarlatina it occurs generally during the period of 
desquamation, from the twelfth to the nineteenth day from the commence- 
ment, and is caused by exposure to cold or change of temperature. It is 
as frequently met with, relatively to the frequency of these two affections, 
after intermittents as after scarlatina. Indeed, one of every six cases col- 
lected by the authors followed the former. It was in these cases chronic, 
and contributed, with the other complications, to produce a fatal termi- 
nation. 

When avoidance of exposure to cold, which should always be attended 
to, has not prevented an attack of nephritis, free bleeding, with warm 
applications to the back, or warm baths, and warm, soothing and nitrous 
drinks, should be immediately resorted to, and after bleeding saline purga- 
tives may be employed with great effect. Vapour baths are highly recom- 
mended, to be given in bed regularly and successively. They were used 
by the authors in most of the cases which recovered, and tend to substitute 
the action of the skin for that of the kidneys, allowing these latter organs 
to rest. They are in some cases advantageously combined with the use of 
digitalis and nitre. 

The authors have never recognized the existence of inflammation of the 
pelvis of the kidneys or pyelitis during life, though they have met with 
evidences of it after death. Hyperaemia and anaemia of the kidneys, 
appearing to be either the precursory condition or the consequences of 
simple or albuminous nephritis, and not having been recognized during 
life, present no useful practical considerations, either diagnostic or thera- 



1844.] Rilliet and BsiYihez on the Diseases of Children. 137 

peutic, and we therefore pass them by and direct our attention to the 
inflammation of the encephalic and spinal organs, which alone of the 
internal organs, remain to be studied in this relation. 

By considering, in a subsequent part of the work, inflammation of the 
meninges of the brain, as connected with tubercles, the authors have, as 
they remark, much diminished the importance of the present section. 
For "although it is a common saying, that most of the inflammations of 
children concentrate themselves in the head, we shall see that this is far 
from being the fact," when we abstract the tuberculous cases. Meningitis, 
apart from the tuberculous diathesis, has not been described, and MM. 
Rilliet and Barthez have been compelled to make up their account of it from 
the examiiiation of only six cases, (five of their own, and one communi- 
cated by M. Legendre,) they having failed to find any others in the records 
of science upon which they could rely as being unconnected with tubercles. 
It is necessarily, therefore, imperfect, and must be regarded rather as a 
sketch to be filled up by future observers, than as an exact and full descrip- 
tion of this disease, which consists in "an inflammation of the free surface 
of the arachnoid or of the pia mater, without tubercles either in the me- 
ninges, or in other parts of the organism." 

The evidences of meningeal inflammation were, an alteration of the 
products of secretion, the arachnoid itself being smooth, polished, and 
transparent, while its cavity was found to contain pus, either in a liquid 
state, or, from much of its watery particles being absorbed, resembling 
false membranes. At the same time the meshes of the pia mater, itself 
brightly injected but without thickening or softening, were infiltrated with 
pus in great abundance, and over a large extent of surface, always upon 
the convexity, and in five cases out of six at the base also: sometimes the 
ventricular linings were also inflamed, and within the ventricles a small 
quantity of troubled secretion, and once pus, was met with, the brain itself 
being perfectly consistent and healthy. 

The attack commences with considerable fever, intense headache, gene- 
rally frontal, anorexia, bilious vomiting and great thirst, with profound 
alterations of the intelligence from the first day, alternating with stupor, 
agitation, delirium and coma. The symptoms rapidly increase in violence, 
with irregularity of the pulse, anxiety, embarrassed respiration, subsultus 
tendinum, tetanic symptoms, &c., ending in death at a period varying 
from thirty-six hours to nine days. The prognosis is, in the opinion of 
the authors, extremely unfavourable in this disease, from the rapidity of its 
march; and the indications for treatment require to be met by free bleeding 
both general and local, at the outset, the application of ice and cold com- 
presses or aff*usion to the head, the use of the cups of Junod, or dry cup- 
ping by large cups applied upon the extremities. An early resort to 
mercurials, with a view to their constitutional action, revulsives, purgatives, 
absolute repose and quiet in a well-aired room, is demanded, and as a last 
resource, a blister should be applied to the head. 

Two of the cases analyzed in the chapter under consideration, resulted 
from causes acting directly upon the head, one from insolation, and the 
other from exposure of the scalp, red and inflamed, after the fall of the 
scabs of a chronic eruption, which involved the greater part of it, had been 
obtained by the application of a large poultice. This aff'ection would 
also appear to occur at times as an epidemic, an account of such a circum- 
stance having been published by Dr. Albert in Htifeland's Journal for 

12* 



138 Review. \J^V 

1830 ; it is there stated that one hundred and fifty children were attacked 
with it in Berlin in the course of about two months. An abstract of this 
paper is given by the authors in the historical account appended to this 
chapter. 

A short chapter follows on the diseases of the cerebral veins and of the 
venous sinus of the dura mater. These are chiefly interesting in an ana- 
tomical point of view, and the authors content themselves with giving an 
abstract of a paper published by M. Tonnele, having themselves met with 
but very few instances of phlebitis of the sinus. They observe, with 
respect to cerebral congestion, which has been made to play so important 
a part in the diseases of children, that they find no symptoms necessarily 
attendant upon it, and that they have quite often met with the symptoms 
attributed to this condition of the brain, among which convulsions occupy 
a prominent place, when no such congestion could be discovered : nor have 
they any evidence when this was found, that it was not rather a conse- 
quence of, than an original condition giving rise to, the convulsions. 

Encephalitis, or softening of the brain, so frequently observed in old 
age, is very rare in childhood ; MM. R. and B. stating that they have 
only met with it, 1st, in children, who having died of different diseases, 
presented more or less serosity in the ventricles with an oedematous soft- 
ening of the fornix, the septum lucidum, and sometimes the ventricular 
parietes, which did not reveal itself by any symptoms during life ; and 
2d, in cases where the softening was secondary to old cerebral lesions, 
and had developed itself around or in the 'neighbourhood of tubercles, 
haemorrhagic collections, &;c. But two cases of idiopathic softening of 
the brain are recorded; one, by M. Deslandes, in which there was soften- 
ing of the whole cerebrum and cerebellum, and the other in the Wochen- 
schriftfur die gesammte heilkunde, 1837, No. II., revealing after death a 
well-marked red softening of the left corpus striatum. Both of these are 
presented by our authors, who have added from Dr. Durand, a very inte- 
resting case, in which the inflammatory lesion is well-marked and at a more 
advanced stage, the formation of pus having taken place, and a collection 
of it having been made in the lateral ventricles and in two cavities in the 
centre of the anterior left lobe. It was attended with severe cerebral symp- 
toms. 

Hypertrophy and induration of the brain, which are united by a com- 
mon characteristic, viz., an augmentation of the density of the cerebral 
pulp, which is also the principal and most appreciable pathological pheno- 
menon, are studied together, and in fact constitute in our authors' opinion, 
one disease. The sole apparent difference is, that in hypertrophy, the in- 
creased volume of the brain is very evident, whilst in induration, this is 
either absent or hardly appreciable. Yet, as the authors remark, this is 
not a sufiicient distinction, for the augmentation of volume, in cases where 
the brain is generally indurated, may consist in an increase in the number 
and volume of the cerebral molecules, filling up the space which previously 
separated them. It is almost impossible to lay down any diagnostic sign 
of this condition : indeed, in one form alone, is it at all probable that it 
will be recognized during life, and that is, in children who have been ex- 
posed to the poisonous effects of lead : in these it may be suspected, when 
severe cerebral symptoms, as headache followed by convulsions, loss of con- 
sciousness and coma alternating with agitation and convulsive spasms, and, 
at the same time, violent bilious vomiting and severe abdominal pain appear; 



1844.] Rilliet and Barthez on the Diseases of Children. 139 

especially when the child is known to have been exposed to this delete- 
rious agency. Its course is very rapid, causing death in four or five days. 
It is sometimes apparently constitutional or congenital, but when acquired, 
has rarely been met with before the sixth year. The only treatment is 
prophylactic, to prevent the attack by removing the child from the action 
of its cause, or by other hygienic means ; for when once developed, the 
disease appears to be beyond the resources of art. In the other cases, 
when the disease seems to have been congenital, and the head has pro- 
gressively and proportionally increased in size with the brain, without 
alteration of the intellectual faculties, or derangement in motility or of the 
organs of the senses, the patient may live for many years, and finally die 
of an affection not necessarily an immediate consequence of the hyper- 
trophy. Where these lesions are partial, they present themselves under 
different forms and cannot, according to the authors, be said to be the same 
affection. We have here, however, a simple narrative of the cases which 
they witnessed with some practical remarks. 

MM. R. and B. next give a short sketch of spinal meningitis, stating 
at the outset their inability to trace its history with desirable accuracy, in 
consequence of their having themselves met with but one case of it, and 
that, too, complicated with tubercles, and of their finding the cases recorded 
by others, complicated either with cerebral meningitis, or softening of the 
spinal marrow. 

A disease of more frequent occurrence is myelitis, or softening of the 
spinal marrow, of which the authors have themselves collected eight cases 
which are analyzed with three others in the chapter devoted to this sub- 
ject. It is sometimes exceedingly rapid in its march, the children dying 
with the symptoms of acute tetanus, while in other instances it assumes 
a more chronic form, revealing its existence by a slight or more marked 
disorder of the muscular system, as by tetanic symptoms, paralysis, &c. 
It more commonly occurs among children over than under six years of 
age, and is, perhaps, not necessarily incurable, as cases of spontaneous 
tetanus have been cured: it is not, however, proved, as the authors remark, 
that in these cases there was softening of the spinal marrow. When it 
does exist, it cannot he mistaken after death, and may be met with in every 
degree, from slight diminution of consistence, to a diiiluent state, of a dull 
white colour, more frequently seated in the posterior than in the anterior 
portions, in the white substance, and sometimes involving the whole thick- 
ness. General and local bleedings, purgatives, warm baths and opium in 
large doses, are recommended in the acute stage, and if they fail in pro- 
curing relief, a resort must be had to mercury and counter-irritation. 

The consideration of the inflammatory affections of the spinal marrow 
is closed by directing attention to the fact, that it may sometimes be indu- 
rated, though the authors do not assert positively that this is an inflamma- 
tory lesion. Two cases of it are noted, in both of which paraplegia was 
observed. 

We have thus presented a general summary of some of the authors' 
views upon the important class of the internal phlegmasiae. The external 
inflammations, among which are included, those of the articulations, of 
the skin, of the cellular tissue and of the ear-lubes, remain yet to be con- 
sidered. 

Acute articular rheumatism is a rare affection in children ; yet the 
authors have collected eleven cases of it, and have had others placed at 



140 Review. [July 

their disposal. In all of these the children had passed the age of seven 
and most of them were between twelve and fourteen years. This disease 
is a slight and easily manageable one, even when complicated with peri- 
carditis, as sometimes happens, though one fatal case has been observed by 
M. Piet. The symptoms are the same as in the adult, though less severe 
and of shorter duration, yielding sometimes in six days and always before 
the fifteenth day. Rheumatism is liable to be confounded, unless care is 
observed, with a form of articular inflammation occasionally met with in 
variola, manifested by the occurrence of pain and swelling, and which is 
sometimes cured by resolution, but in severe cases ends in suppuration, or 
with another form connected with phlebitis, or with a rare and curious 
affection, namely, effusion of blood into a joint, of which several examples 
have been recorded, connected' with constitutional haemorrhage, and pre- 
senting many of the symptoms of articular rheumatism. 

The acute and chronic inflammations of the skin are next passed in re- 
view. Following the classification of Willan, modified by Rayer, and 
discussing in a few brief preliminary remarks, the comparative frequency 
of each order, and the peculiarities they offer, the authors dwell especially 
upon impetigo and favus among the pustular, eczema among the vesicular, 
and roseola and erysipelas among the exanlhematous eruptions, which are 
carefully described in as many difl"erent chapters, and present an excellent 
practical summary of every interesting point relative to the symptoms, 
march and treatment of these diseases. Erysipelas of the face they con- 
sider a very rare affection in children ; that is to say, 

"When it is spontaneous, or occurs in the course of some other affection, but 
independently of all external causes, and when not the result of a disease of 
the integument." External causes, as insolation, friction, a fall, &c., may pro- 
duce it, but, even under these circumstances, it is not easily developed. The 
duration of this disease is from about seven to ten days, and every case of spon- 
taneous erysipelas, observed by the authors, recovered. "Is it not singular, it 
is asked, that precisely at the age, when chronic inflammations of the face and 
of the scalp, are so common, erysipelas should be so rare, and that besides it 
should be so little liable to be attended with cerebral symptoms (as the authors 
show to be the case]") Vol. i. p. 725. 

Cutaneous diphtheritis, induration of the cellular tissue (which last twice 
presented itself to MM. R. and B. under the same circumstances as ana- 
sarca, bore the same appearance, followed the same course, and in fact 
resembled it in every respect, except the hardening of the tissue), and otitis 
are the subjects of the concluding chapters of this first class of the dis- 
eases of children. 

Before leaving this portion of the work, we cannot pass unnoticed the 
opinions herein expressed as to the little danger to be apprehended of 
causing serious accidents by the repercussion of the diseases of the skin, 
and especially of those of the scalp. MM. RilUet and Barthez affirm that 
the eflfects which have been attributed to this cause have been overrated, 
that in many, perhaps, in most cases, disease previously existed in the 
parts which manifest it under such circumstances, — as when by topical 
treatment the aff"ection of the skin had been rapidly cured — and that at 
any rate, the new disease may have been caused by the absorption of pus 
from the inflamed surfaces, or by the state of irritation in the membranes 
of the brain — when this organ is attacked — kept up by the topical treat- 
ment. Though we are compelled in a certain number of cases, to admit 



1844.] Rilliet and Barthez on the Diseases of Children, 141 

the truth of these positions, we cannot close our eyes to the fact that they 
are not always, nor even in the majority of instances correct: indeed, the 
authors themselves confess the risk incurred by proceeding too rapidly in 
the cure of these cutaneous affections, when chronic, and advise that deriva- 
tion should be made upon the intestinal canal by means of purgatives ; and 
the daily experience of practitioners will teach them to be cautious of 
transgressing the practical precept oifestina lente, in attacking these chronic 
disorders. 

The dropsies form the second class of the diseases of children treated 
of in these volumes. They are frequent affections of childhood, and 
besides being active or passive, as among adults, they may be primitive or 
secondary, the primitive being always acute, the consecutive sometimes 
acute, sometimes chronic, or cachectic. Some have doubted whether the 
primitive form, which is confessedly very rare, is ever met with ; but the 
authors set this question at rest, having collected some incontrovertible 
cases. It is in general a mild disorder, attended with a distinct, though 
slight febrile movement, and, according to their experience, always termi- 
nates in recovery. To it ihe acute secondary form bears a considerable 
resemblance, but this is more serious in its consequences, because the 
child is already debilitated by the previous disease. It presents itself 
usually either as a very acute disease, causing death in a few days, or 
even a few hours, or as merely acute, being in this case easily cured, or 
becoming chronic, and then sometimes terminating fatally. 

The cachectic dropsies are frequent, sometimes of short duration and 
almost instantaneously produced. They resemble the chronic form in 
being apyretic, in causing few general symptoms, and in the great enlarge- 
ment they may occasion of the cavities, into which the serosity may be 
effused or infiltrated. The intimate nature of the disease is, in all cases, 
the same, viz., " a serous effusion or infiltration, of which the origin is 
most usually a general modification of the individual." As it frequently 
invades several organs at a time, it is more often a general than a local 
affection. We here meet with a similar remark to that noticed when 
speaking of inflammation, viz., " that robust boys of more than six years 
of age are more subject to the acute and active forms, w^hilst among girls 
and feeble children under six years, the chronic and cachectic forms are 
most usual." Vol. i. p. 750. 

Commencing with the organs of the chest, MM. R. and B. first treat of 
cedema of the lungs, which is one of the most frequent forms of dropsy 
among children, and of which they have collected 77 cases. It has, in 
general, attracted but little attention, and being almost always terminal, 
revealing itself by obscure and almost inappreciable symptoms, it scarcely 
requires treatment ; besides, it is only secondary, and less serious than 
the original and antecedent disease. It is important, however, to bear the 
possibility of its occurrence in mind, as we are told that it sometimes con- 
stitutes a part of those sudden serous affections after scarlatina, and, from 
its intensity in these cases, endangers the lives of the young sufferers. 
Obscurity of the respiratory murmur and sub-crepitant rattle, as indicated 
by Laennec, are the only stethoscopic signs which can be relied upon as 
revealing this disease; but it is difficult to ascertain their existence when 
caused by this state of things, as so many other affections of the organs of 
respiration are apt to mingle their sounds with those produced by this. 
The oppression of the respiration is always marked, and is greater in pro- 



142 Review. [July 

portion to the extent of the oedema and the rapidity with which it takes 
place. 

Hydrothorax "merits attention in but a very small number of cases, 
being fatal when it occurs at the termination of a serious disease, and only 
presenting a chance of cure when it is acute itself, and the consequence of an 
acute disease." Vol. i. p. 763. Its certain existence can only be ascertained 
when there is a concurrence of great oppression, dulness, or diminution of 
sonorousness, obscurity or absence of the respiratory murmur, and at the 
same time absence of pain in the side. In many cases, as in the adult, 
the effusion probably takes place during the last hours of life, or even at 
the moment of death. 

Hydropericardium is rare among children, and furnishes no interesting 
points for consideration, manifesting itself by no particular symptoms; 
indeed, the only lesion met with in the six cases analyzed by the authors 
was a comparatively very inconsiderable quantity of serosity in the peri- 
cardium. These two affections must be treated on general principles, 
according as they are acute or cachectic, squills and digitalis being com- 
bined with other general or local remedies. 

MM. Rilliet and Barthez have analyzed 25 cases of ascites. They 
remark " that very young children often have the abdomen large and 
developed, so as, at first sight, to lead to the suspicion of their being 
ascitic; the error is more liable to be made if there is some oedema of the 
legs, and more especially of the abdomen; in this last case, in effect, a false 
fluctuation is often felt; the nature of the disease may be ascertained, 1st, 
by the pitting upon pressure; 2d, by the interposition of the hand pressing 
lightly upon the abdomen between the two points where the fingers are 
placed to seek for the fluctuation." P. 768. In a very young child fluctu- 
ation may be ascertained by having it held with the abdomen downwards, 
and then examining by percussion at the umbilicus. 

Primitive ascites they consider a very rare disease, having only met with 
six cases of it; at any rate it is not a very serious form, and its spontaneous 
cure is not deemed at all impossible. As regards the cases of Dr. Wolff, who 
asserts that he has seen 100 in six years, MM. R, and B. say they fear "there 
has been some error of diagnosis; for at the same time that he affirms that 
the fluctuation was undoubted, he says that the mesenteric glands became 
enlarged. How could he ascertain this positively, seeing that he never 
made an autopsy of the disease?" A resume of his work, taken from the 
Bulletin des Sciences Medicales is, however, given, that all may judge for 
themselves of the accuracy and applicability of his statements. The acute, 
active, secondary form so closely resembles peritonitis, that it is only dis- 
tinguishable from it by the concurrent existence of dropsy in other parts of 
the body. The effusion is never very great, the march may be very rapid, 
in which case the prognosis is that of peritonitis — it being a very serious 
affection — and the treatment is the same as that directed in secondary 
peritonitis. 

The chronic or cachectic secondary form of ascites is only serious in 
consequence of the extensive development of the cavities to which it may 
give rise, and the gradual increase of the cachectic disposition which 
may attend it. As regards paracentesis, the authors think that "it is 
rarely necessary to perform this operation, for it is only in a very small 
number of cases that the effusion is so great as to distend the abdominal 
parietes sufficiently to cause suffocation and the other accidents which 



1844.] Rilliet and Barlhez on the Diseases of Children. 143 

require a prompt evacuation of the liquid. . . We only admit it as the 
last resource, and in very rare cases." Vol. i. p. 774. 

Hydrocephalus, according to the authors, results '-'from the effusion or 
infiltration, not inflammatory, of a liquid into the cranial cavities, or into 
the cerebral substance." QEdema of the brain is admitted to exist when- 
ever a white softening of the central parts is met with, and is very often 
the result of the direct infiltration of the ventricular serosity into the cere- 
bral pulp. Hydrocephalus is almost always a consecutive affection, and 
may be either acute or chronic. Its importance, in the acute form, has 
been greatly diminished by the modern discovery of the dependence of 
serous effusion in the encephalon upon tuberculous meningitis, and, indeed, 
it is difficult to establish the fact of the presence of the affection we are 
considering, "the only symptoms which the authors have been able to 
refer to it being great agitation, cries, or constant moaning, succeeded, a 
little before death, by extreme prostration and stupor, loss of conscious- 
ness, coma, or even general insensibility, with dilated pupils, and a fixed 
stare." These, however, were not constant, nor were they all met with 
in the same cases. Acute hydrocephalus may be met with in all these 
diseases, which are often complicated with anasarca, as scarlatina, rubeola, 
gangrene. Sic, and under this title should be classed those cases which 
have been described by authors as instances of serous apoplexy. The 
authors, like MM. Guersant and Blache, have never met with a case of 
primitive hydrocephalus, though such have been recorded, though at a time 
when the examination of the encephalic organs were made with less care 
than at present. 

Chronic hydrocephalus is a more important form of disease. The 
authors do not believe that as a primitive acquired disease it has ever been 
met with, notwithstanding the assertions which have been published to the 
contrary; nor is this at all astonishing; for, as we are told, it is not at all 
proved that primitive chronic dropsy of any kind occurs in children. Cases 
which appear to authorize the belief in its possible occurrence have been 
published, and are transcribed by the authors in the chapter under con- 
sideration, but they are very doubtful. Be this as it may, this form may 
be either congenital or acquired; the cases here analyzed are chiefly of the 
latter class. The authors, after stating that they do not agree with M. 
Breschet in ascribing these arachnoidean effusions to inflammation of the 
meninges, as they have never seen them result from this cause, attribute 
them more frequently to the development of a tumour — and this, too, 
generally of a tuberculous or cancerous nature — in the cranial cavity, 
causing a compression of the venx Galeni or of the siyius rectus, and thus 
obstructing the circulation, or to any other cause interfering with the free 
passage of the blood through the sinus. The difficulty of treating this 
affection depends upon the nature of the cause which produces the symp- 
toms observed; even if we were able to remove the efiusion, the lesion 
causing it still remains to reproduce the same effects. The authors doubt 
the propriety and efficiency of compression by means of adhesive strips, 
both from the risk incurred of causing pressure of the brain, and on 
account of the transpiration from the skin being thereby arrested. Tap- 
ping, which is reported to have been attended with success in some cases, 
is not applicable, they think — notwithstanding the cases published by Dr. 
West — to this form of hydrocephalus, for the reason above given, that 
though the fluid is evacuated, the cause of its effusion still remiains behind; 



1 44 Review, [July 

but they admit that it may be useful in another form, consequent upon 
a hemorrhage into the cavity of the arachnoid. We cannot take leave of 
this subject without directing attention to the authors' experience in cere- 
bral auscuhation, vi^hich they give in the following remarks. 

" Dr. Fisher, of Boston, has asserted that the ear applied to the head, and 
especially on the anterior fontanelle, can perceive a distinct bruit de souffle in 
this disease. We have never been able to recognize this sound in acute or 
chronic hydrocephalus; MM. Barth and Roger have also failed to do so. On 
the other hand, we once perceived it in a child which, judging from the size of 
the head, was believed to be hydrocephalic; yet upon examination after death, 
the brain was found in a perfectly healthy condition." Vol. i. p. 796. 

Anasarca is a disease of much importance, says MM. R. and B., whe- 
ther we consider the conditions under which it occurs, or its frequency. 
They have met with it in more than one-eighth of the patients they have 
observed, and present an excellent description of its symptoms and appear- 
ances, and of the circumstances under which it arises. Primitive anasarca 
is becoming more and more rare, we are told, as the advances in patholo- 
gical anatomy disclose some hitherto unrecognized lesion to which it might 
be traced; but six cases of this form have fallen under their observation, 
occurring mostly in boys in good health, of good constitution, and between 
the ages of six and fifteen years. It is a light affection, was cured in each 
case, and should be treated — as also the acute secondary form, which much 
resembles it in its phenomena, — by antiphlogistic cooling drinks, sudorifics, 
diuretics, among which digitalis, squills, and nitre, are most highly recom- 
mended, and purgatives, when the intestinal canal is ascertained to be in a 
healthy condition. Of the secondary form, 155 cases, of which 79 were 
acute and 76 chronic or cachectic, have been collected and are analyzed. 
"Almost all the diseases of children, acute or chronic, may be complicated 
with anasarca, which is either acute or chronic, concomitant with, or posterior 
to the primitive disease, and is induced either by an excess or deficiency 
of the plasticity of the blood, or by some unknown condition of that fluid, 
or by an obstacle to the course of the venous blood, or by a disease of the 
skin and more especially of the lymphatic network, or finally by an affec- 
tion of the kidneys, of which the mode of action is still obscure." Vol. i. 
p. 834. It most frequently occurs between the ages of two and five years, 
and, in its chronic and cachectic form, in girls and children of feeble con- 
stitution, and should be treated in reference rather to the primitive disease 
upon which it is engrafted, and to the constitution of the child; the cachectic 
form requiring the use of tonics, as ferruginous preparations, generous 
diet, bark, and frictions upon the skin. 

We have thus passed cursorily over the matter contained in the first 
volume of this excellent treatise, and have reached the third class of dis- 
eases, according to the arrangement laid down by the authors, the hemor- 
rhages, with the consideration of which the second volume opens. These, 
as we are told at the outset, are among the least interesting diseases of 
childhood, being rare, almost always secondary, frequendy latent or 
obscure, and only revealing themselves when the sanguine discharge can 
take place externally or occupies an organ accessible to sight. They are 
much less frequent than the dropsies, though they would seem often to 
result from the operation of the same causes The plethoric active forms 
are extremely rare under the age of ten years, and are almost exclusively 
met with after this period, especially in girls; while the chronic andgachectic 



1844.] Rilliet and Barthez on the Diseases of Children. 145 

varieties are much more frequent between one and five years, the latter being 
almost exclusively passive, arising either from the want of due plasticity 
in the blood, or from a material alteration of the substance of the organic 
tissues or a perforation of the vascular parietes, which is much more fre- 
quent in childhood than at any other age. There is one form of hemorrhage 
■which is almost exclusively met with in childhood, viz : the constitutional, 
which is evidently dependent upon some hereditary and constitutional 
predisposition. It is to be regretted that the authors have made no inves- 
tigations, as to the alterations of the blood itself, which must evidently 
have more or less influence in determining the occurrence of hemorrhage; 
for if they had pursued this subject with the same intelligent and perse- 
vering industry, which they have brought to bear upon almost every other 
point touched upon in these volumes, it cannot be doubted that they would 
have added much and very valuable information upon haematology. With- 
out doubt their future labours will be directed to this among other interest- 
ing matters. 

The preliminary chapter contains a good general account of the pheno- 
mena of hemorrhages, of the modifications they exhibit when occurring in 
a serous or mucous membrane, or in the parenchyma of an organ, of their 
different forms, whether primitive or secondary, acute, chronic, or cachectic. 
Of the causes, of the prognosis — favourable in primitive cases, less so in 
secondary cases, though the nature of the primitive disease, the number of 
the organs attacked, and the copiousness of the hemorrhage must be con- 
sidered in forming our opinions in these cases — and of the treatment 
which is generally applicable, but which must be modified according to the 
form of the attack, the cause and copiousness of the bleeding, the con- 
stitution and condition of the patient. The hemorrhages of the lungs, 
of the brain and of the skin, being the most important of the class, have 
received especial attention from the authors, those of other parts, being 
also treated of, but with less detail. 

Pulmonary hemorrhage presents itself under two forms, hasmoptysis, 
when the fluid is rejected, and pulmonary apoplexy, when the blood is 
extravasated into the substance of the lung, this organ either preserving 
its vesicular character or being broken up and disorganized. Hcemoptysis 
is not frequent among children, MM. R. and B. having only met with two 
cases of the primitive form in girls, where the discharge was small in quan- 
tity, a few in tuberculous children, where it was almost always terminal 
and the cause of death, and four cases complicating gangrene of the lungs. 
The appearances of pulmonary apoplexy were encountered in twenty-two 
cases of children dying of various diseases. The existence of these lesions 
was not generally ascertained during life ; and when any symptoms were 
observed indicative of this disease, it was usually only the day previous to 
the child's death : indeed, no special symptoms can be pointed out. Four 
of the patients died of suddenly fatal (foudroyante) hemorrhage, two of 
these from rupture of one of the vessels of the lungs, but without the 
occurrence of haemoptysis, in either. These apoplectic attacks occurred 
most frequently in boys of or over five years of age and most generally 
in the course of pulmonary or bronchial tubercles, hemorrhagic variola, 
scarlatina, nephritis, colitis and secondary pneumonia. 

Hemorrhage in the pleura, epistaxis, and hemorrhage of the stomach 
and intestines are briefly considered in separate chapters. The two last 
are very rare, and the authors doubt, from the facts they have consulted, 
No. XV.—JuLY, 1844. 13 



146 Review. [July 

whether haematemesis has its origin in the discharge of blood from the 
vessels of the stomach, believing that it takes place in consequence of the 
flow of blood from other parts, which becomes lodged in the stomach and 
is thereupon rejected. Intestinal haemorrhage, they state, has only been 
observed in the course of hemorrhagic eruptive fevers, of typhoid fevers 
and purpura, or in cases of tuberculous ulceration, causing the lesion and 
opening of a vessel of some size, or when an intestinal arteriole has 
been perforated by a lumbricus. Renal hemorrhage has been met with 
almost exclusively in eruptive fevers, and to the accounts of these last we 
are referred by the authors for their remarks respecting this symptom. 

A much more important and interesting series of cases now demands atten- 
tion, and has been studied by the authors with even more care than they have 
uniformly devoted to their investigations. We refer to cephalic hemor- 
rhages. These may be seated, either under the scalp — these are very 
rare after the first year, although frequent in new-born children, but may 
occur above or beneath the pericranium, causing^ serious accidents — or 
between the dura matter and skull, or between the dura matter and arach- 
noid — neither of them presenting much practical interest, either in diagno- 
sis or therapeutics, the latter, in fact, being much more rare than is gene- 
rally supposed, the effusions being found to be actually effusions into the 
cavity of the arachnoid, though ecchymotic spots are sometimes met with 
external to this membrane — or finally within the cavity of the arachnoid. 
These last are by far the most interesting. The hemorrhage may be so 
great as to simulate actual hydrocephalus, as was the fact in the cases 
collected by the authors. Pure liquid blood, we are told, is very rarely 
found in the arachnoid cavity, for after its effusion, it is rapidly separated 
into a liquid serous part and a coagulum. This last undergoes various 
transformations—its colour changing from a red or even blackish tint to 
yellowish red or even yellow — as the result of which it passes into the 
condition and appearance of false membranes, delicate, elastic, more or 
less resisting, resembling sometimes the arachnoid itself in delicacy and 
transparency, at others a really fibrous membrane, becoming opaque, tena- 
cious, and even, perhaps, as in the adult, stratified. The authors trace 
these clots, sustaining their views by appropriate post-mortem examina- 
tions, from the first moment of effusion to the false-membranous appear- 
ance described above ; they are either single or several, their edges pro- 
longing themselves into very thin layers, sometimes floating by one edge 
in the serous liquid and attached by the other to the arachnoid, sometimes 
to both of its surfaces, from which they are easily detached, leaving this 
smooth and transparent above, though the visceral portion often presents 
marked lesions, becoming thickened, opaline and resisting, so that it may 
be raised in a single layer, leaving the brain beneath perfecdy healthy and 
rarely even congested. These clots have been mistaken for false mem- 
branes, the consequences of inflammation, and many cases of hydroce- 
phalus actually resulting from hemorrhage have erroneously been attributed 
to inflammation of the arachnoid passed to a chronic state. The authors, 
however, state, that the only source to which they can trace these appear- 
ances, with any degree of satisfaction, and in accordance with facts, is to 
sanguine exhalation. 

Except in cases where the effusion is so abundant as to constitute 
hydrocephalus, it is rare to observe any symptoms characteristic of the 
disease, that are not equally met with in other encephalic affections, 



1844.] Rilliet and Barthez on the Diseases of Children. 147 

which may even be concomitant with it. Even when hydrocephalic 
symptoms are present, we can do nothing more than ascertain the fact, 
without discovering the cause. We must therefore, say the authors, rely 
on other circumstances to assist in forming the diagnosis. Among the 
most important of these is the following. " We (the authors) have never 
seen a child two years old and under, die hydrocephalic in consequence of 
cerebral tubercles ; the disease was in them caused by sanguine effusion, 
and it is only when the head has begun to develope itself after two years 
of age, that we have found tubercles or other cerebral tumours with hydro- 
cephalus (the authors, however, admit that instances of tuberculous ventri- 
cular hydrocephalus have been reported, one in particular by Constant). 
Can sanguine effusions, after the age of two years, give rise to hydroce- 
phalus? We have no example of it, though we cannot affirm that it is 
always so." Vol. ii. p. 46. Another method of ascertaining the nature of 
the fluid, is to make an explorative puncture, which, in cases of doubt, 
the authors do not hesitate to recommend, judging by the character of the 
evacuated liquid and the depth to which it is necessary to penetrate, of 
the seat of the disease. The importance of ascertaining this fact is con- 
sidered by the authors as very positive : for they think that it is in cases 
of this kind that the treatment of Golis has been successful; and in the 
event of this disease being diagnosed, they recommend its immediate adop- 
tion to promote absorption, and if, after a reasonable trial, it should fail, 
they advise having recourse to puncturation in order to discharge the 
liquid, before the clots have been too completely transformed. 

Hemorrhage into the meshes of the pia mater, they have never met 
with, though cases of it are reported by others. Cerebral hemorrhage 
loses much of its importance in children ; of slight extent and rarely pri- 
mitive, it is either latent, or appears only during the last days of life, or 
during the course of a disease, itself mortal. At any rate it is extremely 
difficult to distinguish the encephalic haemorrhages from each other. It 
would appear, however, the authors think, " that the convulsive form of 
symptoms belongs more especially to meningeal apoplexy, whilst the 
inflammatory symptoms are mostly met with in cerebral hemorrhage 
itself." Nor is there difficulty in diagnosing these from other affections 
of the encephalon. Previous disease, the injudicious treatment of chronic 
affections of the scalp, a cachectic tuberculous disposition, and, in an espe- 
cial manner, an obstruction to the circulation, particularly the venous and 
sub-diaphragmatic portion, are among the most prominent causes of these 
hemorrhages. All authors agree that cerebral hemorrhages are very 
rare in children, while some affirm that those of the meninges are fre- 
quent. They have, however, scarcely attracted the attention of writers. 
The conclusion to which MM. Rilliet and Barthez have arrived, has been 
corroborated by a paper published by M. Legendre, about the same time 
that their first memoir upon this subject appeared in the Gazette Medicate. 

A full and interesting account of purpura, concludes the subject of the 
hemorrhages, and we are thus brought to the consideration of the fourth 
class of diseases — Gangrenes, which "form, in the pathology of childhood, 
one of the most marked and distinct classes of disease, from the uniformity 
of their aspect, of their course, of their causes, and of their gravity. Most 
generally fatal, (jangreneis happily, comparatively infrequent, and ordinarily 
supervenes in the course of diseases already fatal of themselves." Vol. ii. 
p. 99. The skin, mucous membrane and lungs are most liable to gan- 



148 Review. j^July 

grene, and it is to the study of the circumstances connected with its appear- 
ance in the mouth, pharynx, lungs and skin, that the authors confine their 
attention in this work. Gangrene is generally very rapid in its march, its 
fatal termination being dependent as much upon the disease which it com- 
plicates, as upon itself, though the nature of the tissue and the form of the 
mortification have an evident influence upon it. The eruptive fevers and 
especially rubeola, are the most common determining affections, and inflam- 
mation, though it rarely causes it, may predispose certain organs to its 
attack, as the pharynx in scarlatina, rubeola and variola, the lung in rubeola, 
&c. Gangrene is chiefly met with between the ages of three and five, , 
endemic in most cases, epidemic occasionally, and manifesting, in this case, 
a tendency to attack several organs at a time. It is the result of a general 
condition, and not of a local one, reacting upon the economy : what this 
general condition is, the authors do not pretend to say. It should be coun- 
teracted by a tonic treatment, whilst topical remedies, among which cau- 
terization is the best, should be employed to limit its extent. 

Gangrene of the bronchial tubes is first treated of. It is generally con- 
secutive to that of the lungs, though cases are met with independent of 
this condition, one of which is reported by the authors, having occurred 
in a girl eight years old, in the left bronchus, without corresponding gan- 
grene of the lung. 

This last is not a frequent affection, being always, or almost always second- 
ary. Sixteen cases of it analyzed in the chapter before us. Fetidness of 
the breath, so important a symptom in the pulmonary gangrene of adults, 
is often wanting in the child ; indeed, the diagnosis of this condition is very 
difficult, and can only be established by grouping together various symp- 
toms, most of which are often absent, such as sudden prostration, fetid and 
gangrenous breath,- — when no gangrenous lesion of the throat or mouth is 
present — the occurrence of haemoptysis, the blood or expectoration becoming 
gangrenous in odour, &c. This last symptom of haemoptysis so rarely 
encountered in children having occurred in this connection four times in 
sixteen cases. The prognosis is fatal, though if there is possibility of 
recovery, our imperfect means of diagnosis, preventing our ascertaining the 
fact. It may develope itself in the course of pneumonia, though the authors 
assert that they have never met with an example of primitive pneumonia, 
terminating in this manner, nor have they ever seen it occuv (T embUe in an 
individual in perfect health. They think it probable that it may succeed 
a sanguine effusion or an apoplectic congestion of the lung, in consequence 
of the putrefaction of the blood poured out, and they consider it proved 
that it may occur in a nearly healthy pulmonary tissue: but in all these 
cases there must be present a general condition of the system which pre- 
disposes to such attacks. To bring about this predisposition, the eruptive 
fevers, and rubeola in particular, exert the most decided influence. As 
respects the treatment, the authors remark, "When a disease escapes our 
diagnosis and is only discovered after death, it is impossible to lay down 
any rules for its treatment ; we must, therefore, be guided by analogy, 
when its existence has been ascertained." Vol. ii. p. 122. 

Gangrene of the pleura is only interesting as an anatomical lesion ; it 
reveals itself by no special signs, and therefore offers no therapeutic indi- 
cations. Gangrene more frequently occurs in the mouth, than in any other 
part of the body, belongs peculiarly to childhood, and is almost necessarily 
fatal. The subject of the chapter under consideration is cancrum oris, 



1 844.] Rilliet and Barthez on the Diseases of Children, 149 

gangrene of the mouth, properly so called, and not the gangrenous 
aphthae of children. It manifests itself in children, under miserable hygi- 
enic circumstances, in the course of, or during convalescence from, some 
acute or chronic affection, by an ulceration of the mucous membrane, 
sometimes gangrenous from the outset, or by oedema of the cheek : the 
mortification extends rapidly, occasioning perforation of the cheek, denud- 
ing of the bones, <fec. The termination of the disease, whether aban- 
doned to itself, or in spite of treatment, is constantly fatal. Of twenty- 
nine cases reported but three recovered. Topical treatment by caustics 
should be immediately resorted to, at the same time that the strength is 
supported by nutritious diet and tonics. 

Gangrene of the pharynx is a rare disease. In very young children, 
where there is difficulty of making an examination of the throat, it may 
be suspected whenever the breath is fetid and gangrenous, while the respi- 
ratory organs perform their functions well, and there is no gangrenous 
expectoration, the cheeks being at the same time free from cancrum oris. 
It is desirable to distinguish it from that form of pseudo-membranous 
angina, in which patches of grayish-black and very fetid false membranes 
are met with. At the outset, there is hardly room for mistake, as these 
patches do not assume this appearance at once, while at a later period, the 
application of a caustic will immediately clear up the case by changing the 
character of the pseudo-membranous inflammation. In other respects the 
diagnosis is not very important, this lesion being a secondary one and 
almost necessarily fatal, occurring generally in eruptive fevers, and to be 
treated by washing the throat with solutions of chloride of lime, by astrin- 
gent gargles of bark, &c., and the use of tonics. 

The last chapter of this section relates to gangrene of the skin and of 
the external genital organs. It is considered under two heads ; that " which 
is improperly called spontaneous gangrene, which is in fact the conse- 
quence of arteritis, or at least of the formation of a clot in the arteries, 
following a peculiar course, and exclusively occupying the extremities," 
and that which, not the result of arterial obliteration, occurs upon the skin 
either covered with, or deprived of its epidermis, and indiflferently upon 
all parts of the body. We can only advert here to the authors' opinions 
respecting the action of blisters as a cause of this affection — opinions, 
which are certainly well founded, and cannot too often be repeated and 
too strongly borne in mind in practice. " It is remarkable," say they, 
" how easily in children, under some circumstances, blistered surfaces 
assume a gangrenous aspect; this tendency, as well as that to ulceration 
and to cover themselves with false membranes, is one of the causes why 
blisters should be banished from the therapeutics of young children. For 
ourselves, we have had but few opportunities of witnessing the gangrene 
of blistered surfaces, because in the services we have followed, the physi- 
cians have avoided the application of these agents." Vol. ii. p. 198. They 
remark, afterwards, in an appendix to these volumes, *'we do not think, 
however, that we should deprive ourselves entirely of the resources offered 
by this energetic derivative ; though it should only be employed under 
circumstances clearly warranting it." Vol. iii. p. 707. 

The fifth class of diseases, which we have now reached, the neuroses, or 
" apyretic diseases characterized by a trouble of the functions of the ner- 
vous system, which itself presents no appreciable lesion," comprises per- 
tussis, spasm of the glottis (Kopp's asthma), convulsions, chorea, con- 

13* 



150 Review. [July 

tractions and essential paralysis. Epilepsy and hysteria, which belong 
more particularly to adolescence and adult age, spontaneous tetanus, which 
is most generally connected with some affection of the spinal marrow, and 
neuralgia which is almost unknown in childhood, are not studied by the 
authors. 

As an additional reason to those usually urged in support of the opinion 
which regards pertussis as a nervous affection, MM. Rilliet and Barthez 
state that the same convulsive paroxysmal cough with similar intermissions 
which characterizes this disease, is observed in cases where the pneumo- 
gastric nerve lies in contact with, and is probably compressed by, tubercu- 
lous bronchial glands, as well as in cases of traumatic lesions of this same 
nerve. It is hardly necessary, however, to multiply proofs of this fact, 
which is now pretty generally admitted, though it is difficult to account 
for the specific characters of its symptoms and of its mode of propagation. 
The danger in whooping-cough, arising chiefly from the complications, 
the authors devote much space to their consideration, and to fixing carefully 
the character and duration of the symptoms which are usually met with. 
The complications are studied under three heads. 1st, Those which may 
be considered as of the same nature as the disease, viz. convulsions and 
spasm of the glottis, the former being very far from infrequent, though 
peculiar to very young children, occurring during the second stage, and 
being of a very serious character. 2nd, those connected with it by their 
seat or by their local phenomena, as bronchitis — -which is, by some, said 
to be always present, but which the authors only observed alone or united 
with pneumonia in about one-half their examinations, being more frequent 
the longer the disease lasted— pneumonia, — which, as before mentioned, 
generally coincided with bronchitis — and tuberculization, which is far from 
being a rare complication, though it usually manifests itself during the third 
period, and is, in a great majority of cases concentred in the lungs or 
bronchial glands, or at least, is in excess there. Emphysema has been 
spoken of as a complication ; but, as the authors shows unless inflamma- 
tion of the lungs or bronchi was present, this was never met with ; and 
even when they complicated whooping-cough, emphysema was propor- 
tionably less frequent than when they were unconnected with it. Indeed, 
the mechanism of pertussis would authorize us to make this inference, in- 
dependently of post-mortem examinations, for each paroxysm consists of 
a series of forced expirations, followed by insufficient and difficult inspi- 
rations, which do not allow the air to reach and distend the smaller bron- 
chial tubes and the vesicles of the lungs. 3d. Other complications, which 
are rather coincidences, as they have no other connection with the princi- 
pal affection. 

The diagnosis of this affection from bronchitis with spasmodic and 
paroxysmal cough, especially in the latter stages of both, and from tuber- 
culization of the bronchial glands — '* a distinction both important and deli- 
cate to make; important, because it is a question of distinguishing a disease 
susceptible of cure from one almost necessarily fatal; delicate, because 
whooping-cough being sometimes followed by phthisis, it is very difficult 
to ascertain which is cause and which effect" — is clearly laid down by the 
authors in their valuable chapter on pertussis, which would well repay 
perusal. In the treatment of pertussis, they do not advise attempting to 
jugulate the disease, but that every effort should be made to diminish the 
intensity of its symptoms and to prevent complications. They think 



1844.] Rilliet and Barthez on the Diseases of Children, 151 

highly of belladonna, among the narcotics, though its good effects are far 
from being generally believed in, and recommend the use of the subcarbo- 
nate of iron, during the second period, in consequence of its evident effect 
in diminishing the duration and intensity of the paroxysms. As a last 
resource when the rational or empirical remedies have been exhausted, 
vaccination remains to be tried. " The English authors in particular," they 
say, " have published unquestionable cases of its efficacy. It is true that in 
France similar results have not been obtained ; but the trials with it are 
not yet sufficient to admit of a final decision of the question of its utility."' 
Vol. ii. p. 244. A sufficient number of cases have been published, we 
think, to give warrant to the belief that its adoption may both abridge 
the duration and diminish the intensity of the symptoms ; at any rate, 
there can be no harm in vaccinating a child at this time, if the operation 
has not been before performed. 

Spasm of the glottis or Kopp's asthma has been observed by the authors 
in but one case. Though they admit with some of the German authors 
an opinion, which has also been sustained in this country by a number of 
dissections, that the origin of the disease is, in many cases, pressure of the 
thymus gland upon the bronchi, lungs, arteries, veins and heart, interfering 
with the due performance of the functions of these organs and vessels; they 
state that cases of spasm of the glottis without enlargement of the thymus 
gland are undoubtedly to be met with, and that when hypertrophy does 
occur, it is not necessarily followed by spasm. They believe, in effect, 
with Marshall Hall and most of the English and German authors, that this 
affection is actually a spasm of the glottis. 

Convulsions are the subject of the next chapter. They are treated of 
in this connection for the same reasons which induce the authors after- 
wards to devote a chapter to contractions and essential paralysis, viz. that, 
although sometimes the result of an appreciable cerebral lesion, they are 
also, in other cases, spontaneously developed, or occur during the course 
of affections of very different natures, without our being able to discover 
any relation between the previous disease and the convulsion, or to find 
any appreciable encephalic lesion. Hence they may be either primitive and 
sympathetic of some other affection, without encephalic lesion, or they may 
be symptomatic of encephalo-rachidian disease. The former are much more 
frequent in children under than over one year. Both forms are admi- 
rably described in the pages before us. The occurrence of epilepsy among 
children has been doubted, though we cannot but think without sufficient 
reason, and are not at all astonished at the question proposed by the 
authors, whether convulsions repeated at different intervals are not in fact 
attacks of epilepsy. For themselves, they can see no difference between 
this affection and violent convulsions, save in the repetition of the parox- 
ysms, the symptoms being precisely the same in both, and they agree 
with Baumes, who admits no difference except that which time establishes. 
As regards the diagnosis, if there is hereditary predisposition and the age 
of six years has been passed, there is every probability that these repeated 
convulsive attacks, followed by complete restoration to health, are in fact 
epileptic. They may however be symptomatic of an affection of the brain, 
especially if the child is born of phthisical parents or has lived under bad 
hygienic conditions, as sympathetic convulsions are rare after the age of 
six years. As to cerebral congestion being a cause of this affection, the 
authors agree with the opinions expressed in Copland's compendium, that 



152 Review* [J"ly 

this condition is rather an effect or consequence of the convulsion than the 
cause, though sudden congestion may be productive of convulsions : but it 
is often otherwise and they believe that in these cases, besides, or antece- 
dent to, the hyperaemia, some other lesion of innervation existed which 
was the immediate cause of them. MM. R. and B. recommend, with M. 
Trousseau, compression of the carotids, as a means of relief from convul- 
sions, in cases where the child enjoyed previous robust health, is of good 
constitution, and labours under a first attack, or when it is irritable and 
nervous, and when the attack comes on apparently without cause or after 
some moral perturbation. 

Chorea is not a very frequent disease in the Hopital des Enfants Mala- 
des, to judge from the number of cases reported in this work, which 
amounted to but 19, some of which were obtained from other persons. 
The assertion of M. Rufz, that intercurrent diseases do not modify the 
choreic affection is proved to be inaccurate, and several cases are reported 
in proof of this position. In effect 9 of the 19, experienced more or less 
severe intercurrent attacks, of which the influence w^as marked in 8 of 
them. They were eruptive fevers, w^hich at first exasperated, and then 
caused the chorea to disappear entirely ; sometimes they favoured the 
diminution and cessation of the choreic symptoms from the commencement. 
The treatment of this affection by antispasmodics and tonics is preferred to 
any other, the authors reserving the use of purgatives for those cases in 
which there is habitual constipation or when the disease is kept up, or ex- 
asperated by atony of the digestive tube. In fact the authors cannot en- 
tirely divest themselves of the fear, perhaps real in their hospital practice, 
of creating irritation and inflammation of the intestinal canal, by these 
means. 

Two chapters follow on contractions and essential paralysis, which 
conclude the descriptions of the neuroses, and which we must pass by 
without further notice. 

The sixth class of diseases treated of in the present work, is continued 
fevers. MM. Rilliet and Barthez entertaining v^^ith respect to these affect- 
ions the same opinions as those advanced by M. Littre, define them thus. 
" Febrile affections, without intermission in their course, characterized, ana- 
tomically by an inflammation of the skin or of the mucous membranes, 
having their origin in a general morbid condition, itself probably the result 
of a particular modification of the blood." Vol. ii. p. 338. In this defi- 
nition, are included typhoid fevers, variola, scarlatina and rubeola, which 
are believed to be something more than mere diseases of the mucous or 
cutaneous envelope, the general symptoms appearing before the local 
lesions, which last are very often at variance with the intensity of the 
febrile and nervous symptoms, and, indeed, at times entirely unnoticed. 
Although the eruption in typhoid fever is a much less important symptom 
than in the other enumerated affections, and the mucous inflammation in it 
exceeds the cutaneous, directly the contrary of what occurs in the others, 
they all resemble each other in so many respects as to warrant their being 
grouped together. In their complications, too, there is a difference; for, 
vv^hile the eruptive fevers complicate each other, the same child suffering 
under scarlatina, rubeola, or variola, either succeeding each other, and 
running regularly through their periods, or appearing simultaneously, mu- 
tually influencing each other, and becoming irregular, " it is extremely rare, 
to see typhoid fever developed after an eruptive fever, which, in its turn, 



1844.] Rilliet and Barthez on the Diseases of Children. 153 

never occurs during the febrile period of dothinenteritis." Vol. ii. p. 
345. The eruptive fevers differ again from typhoid in their mode of pro- 
pagation. "Thus, scarcely is a patient, affected with scarlatina, variola or 
rubeola, brought into the wards, before we see several others attacked with 
the same affection ; it is not so with typhoid fever, which has always come 
to the hospital from without, and has never propagated itself within." Vol. 
ii. p. 346. But while the eruptive fevers propagate themselves readily 
within the walls of the hospital, it is remarked by the authors that " it is 
extremely rare to see them develope themselves primarily (^cPemblee) in 
the wards and at a period when no child in them laboured under these 
diseases ; on the contrary, almost invariably one or more children affected 
with one of these eruptions and brought from without, formed the com- 
mencement of a series of cases, which did not cease to increase until all 
the children susceptible of taking the contagion had been attacked." Vol. 
ii. p. 347. 

In respect to contagiousness, the authors find scarlatina to be a little 
more contagious than variola, which is much more so than rubeola: whilst 
rubeola is a little more frequent in the hospital than variola, which is 
much more so than scarlatina. As a prophylactic against these eruptive 
diseases, isolation is the only one worthy of any confidence, and should 
be strictly insisted upon, and especially in those cases, where those who 
would be otherwise exposed to their attacks, are already labouring under 
other affections. 

Such are some of the many interesting and valuable points discussed in 
the preliminary article, which is immediately followed by a chapter on 
typhoid fever. The first monograph upon this disease, as occurring among 
children, which appeared in France, — though it had under different names 
been spoken of by some of the English and German writers — was pub- 
lished by M. Rilliet, in 1839; about the same time a memoir on the same 
subject was issued by M. Taupin, and contained an analysis of a large 
number of cases, which established generally the same results as those 
deduced by M. Rilliet, from his observations. The value and character of 
M. Rilliet's treatise, of which the present chapter may be considered a 
second edition, are fully established by the fact that it has been reproduced 
almost entire by M. Louis in the second edition of his admirable work on 
typhoid fever. 

Typhoid fever is a frequent disease among children, and differs from 
almost all others to which they are liable, in being primitive in the immense 
majority of cases. The lesions by which it is revealed, anatomically differ 
somewhat from those observed in adults, and are thus summed up by the 
authors. 

"1st. We meet in children with the same lesions of Peyer's glands, of the 
isolated follicles and of the mesenteric glands, as in the adult; but the ulcera- 
tions are generally smaller, less numerous and less deep. 2d. The form of the 
alterations of the plates (plaques), observed in the immense majority of cases, 
is that described under the name of soft plates { plaques molles) . 3d. Ulcera- 
tion is not the necessary consequence of their inflammation, which may termi- 
nate by resolution, 4th. Ulceration, when it exists, occurs later than with 
adults. 5th. Cicatrization takes place also with rapidity : we have found it 
complete the thirtieth day; at the third month, very manifest cicatrices may 
still be found. 6th. Ulceration of the membranes is very rare. 7th, Lesions of 
the spleen are far from being constant. 8th. The blood is most generally 



154 Review, [July 

liquid, or in soft blackish clots ; the vessels are often coloured venous red." 
Vol. ii. p. 363. 

In one-fourth of the cases, constipation was observed at the commence- 
ment of the attack, always, however, giving place to diarrhoea at a later 
period ; and the authors notice that vomiting, — which occurred in about 
half the cases, which were generally serious ones — appeared in preference 
among those who were constipated at the outset. The means of diagno- 
sis, the pathological phenomena and the symptoms are ably presented by 
the authors in their long and carefully prepared expositions of these points, 
and might, perhaps advantageously, be dwelt upon. We will, however, 
only enumerate some of the chief symptoms, which are to be relied upon 
in forming a correct diagnosis. They are " a somewhat marked loss of 
strength, though it is often difficult to estimate its degree, agitation, or 
slight nocturnal delirium, copious diarrhoea, accompanied with gurgling 
(gargouillement) in the iliac fossa, prominence of the spleen, numerous 
rose-coloured spots and sudamina, a febrile movement more intense than 
in gastritis, and continuing after the ninth day, and the existence of the 
sibilant rattle of bronchitis," which ordinarily accompanies this disease. 
Vol. ii. p. 382. 

It is clearly shown here, that, contrary to the results obtained by M. 
Louis, in the case of adults, it is impossible in some instances among chil- 
dren to distinguish enteritis from the typhoid fever, they being confounded 
together so as to be inseparable in a considerable number of cases. " The 
predisposing causes of this disease are, the age from eight to fourteen 
years, the male sex, a good constitution, want of acclimation to city resi- 
dence, and an epidemic influence ;" the authors regard with doubt the 
effects of hygienic conditions, as regards nourishment, cleanliness, state of 
habitation, (fee, in producing this disease, and while they do not positively 
deny the influence of contagion, they consider it much less evidently ope- 
rative here, than in many other diseases. 

Convinced of the necessity of employing much judgment and care in the 
treatment of typhoid fever, the authors wisely begin with the remark that 
they recommend no exclusive system — as was the fashion of the day in 
this disease, particularly — but advise a careful appreciation of the symp- 
toms, which will, perhaps, demand a daily modification of the treatment. 
The purgative method, which has been so warmly advocated by those who 
first put it into use, has appeared to MM. R. and B. to have no very evi- 
dent effect, in children, upon the duration of the disease, the fever, the 
state of the digestive organs, or the nervous symptoms ; while they think 
" it is distinctly proved that the repetition of purgatives, especially in very 
young children, is more injurious than useful," in consequence of their 
liability to facilitate the occurrence of enteritis, a disease so easily developed 
in children, and so serious in its effects. Bleeding shall be reserved for 
those cases where it is clearly indicated by the symptoms, and at the com- 
mencement of the attack. The tonic, exclusive, treatment is next exam- 
ined, but the evidence derived from their own experience is so limited as 
not to warrant the authors in making any conclusions from it. 

Vv^e cannot but recall here the fact — though we fear to trespass too 
much upon the reader's patience — that this disease among adults has, of 
late years, been the subject of experiment of every French physician of 
standing, and that it has furnished more victims, perhaps, to experimental 
practice than any other in the nosological table. The most opposite and 



1844.] Rilliet and Barthez on the Diseases of Children. 155 

exclusive methods of treatment have been proposed for its cure, and no 
matter how irrational or absurd all have found warm advocates and victims. 
This system, as barren of useful results as it is unwise and barbarous in 
its institution, is strongly presented in all its horrors by the clever author 
o^ Mysteres de Paris, himself a physician, and the son and grandson of a 
physician. We hope the lesson of morality taught in the following 
extract may not be lost upon our readers. 

" Was the doctor desirous of ascertaining the comparative effects of a new 
and somewhat venturesome treatment, in order to be enabled to arrive at con- 
clusions favourable to this or that system, he would take a certain number of 
patients, treat these by the new method, those by the old, and others he would 
abandon to the sole resources of nature. After which he counted the survivors. 
These terrible experiments were verily a human sacrifice offered upon the altar 
of science." 

Happily for their own reputation, MM. Rilliet and Barthez do not 
sanction, on the contrary, they strongly disapprove of, these exclusive 
systems of practice. Indeed, we may say, without any fear of question, 
that there is no work of the modern French school, which exhibits through- 
out a more judicious and rational system of therapeutics than that which 
we have under consideration. 

Variola is the subject of the next chapter. Our authors admit varicella 
as a variolous affection, rather because the description of others have 
proved it to arise from the same causes and under similar circumstances, 
than because this view is sustained by their own observations. They 
have evidently seen but very few cases of it, only nine, and those mild 
ones. Variola, varioloid, and varicella, are separately and fully consi- 
dered, as respects their course, duration and precursory symptoms, and 
a long, careful, and minute account of the variolous eruption from the ear- 
liest appearance of papular redness to the period of complete desiccation, 
desquamation, &;c., with all its varieties in each form, is presented and 
contains much and valuable information. The concomitant affections, as 
swellings, inflammation of the mucous membranes, (fee, are next studied. 
The means of diagnosing variola in its first stage, before the appearance 
of the eruption, are indicated as far as possible: the authors, indeed, think 
that we may pronounce almost certainly upon the existence of a variolous 
attack, " when a child has fever, constipation, bilious vomiting, if at the 
same time it has not been vaccinated and complains of lumbar pains;" 
more especially if an epidemic of this disease is prevailing, or the child 
has been in any way exposed to its contagion. 

The complications of this disease with other eruptions, are very interest- 
ing. They always aggravate the prognosis, more particularly, however, 
when they come rapidly upon each other, being less dangerous when an 
interval of health separates them. "Thus," say the authors, "we have 
seen a little girl recover from varioloid, scarlatina and rubeola within forty- 
seven days; whilst in two other instances, when the same three eruptions 
appeared within a period of ten and sixteen days, the children died." 
The authors take some pains here, and when studying the subject of tuber- 
cles, to examine into the respective influence of variola and tubercles upon 
each other, the former having been stated to preserve from tuberculous 
disease, giving rise to the inference, that the introduction of vaccination, 
while it protected from variola, increased the tendency to tuberculization. 
The results they present are, that variola and tubercles are in fact repul- 



156 Review. [J"ly 

sive to each other, the former does not immediately engender the latter, 
and when occurring in connection with them appears more frequently in 
cases where the general diathesis is not marked: if it is marked, the variola 
is modified, by being rendered irregular, but when the tubercles are not 
numerous, they tend to pass to a cretaceous state and to be cured. 

" We believe," say MM. R. and B., "that we may conclude without depart- • 
ing far from the truth, that the occurrence of variola has but little povi^er either 
to favour or arrest the predisposition to tubercles. This conclusion cannot apply 
to vaccination, and if, in so serious a question, it were allovi'able to form an 
opinion from a limited number of facts, we (the authors) would say that children 
which have been vaccinated, are more disposed to tuberculization than those in 
which this operation has not been performed. In emitting this result of our 
observations, we anxiously desire that an improper estimate should not be 
placed upon the value we assign to it. We by no means regard vaccinia as a 
cause of tubercles; for we have never seen the chronic affection immediately 
succeed it; we merely note that vaccinated children more frequently die tuber- 
culous than free from tubercles, and that the contrary is the case with children 
not vaccinated : whence we conclude that vaccination very probably favours the 
predisposition to tubercles."* 

These results certainly are curious, and are presented as given by the 
authors ; we do not think, however, that they will impair the credit in 
which vaccination is held at the present day, unless some more decided 
indication of its bad effects are adduced. It undoubtedly renders milder 
the attacks of variola, that once dreaded scourge ; and none would be wil- 
ling to forego this positive advantage from the vague fear of its inducing an 
,equally fatal, though more insidious attack. *'How does it happen," the 
authors ask, " that mild cases of variola, or, in other words, that varioloid 
is so much more frequently met with now than formerly, even in those who 
have not been subjected to this prophylactic treatment? May it not be 
due to the laws of inheritance, the children inheriting from vaccinated 
parents a less marked disposition to contract this disease? If such is the 
case, may not succeeding generations. witness the complete disappearance 
of this disease, as well as of the disposition to contract it." Vol. ii. p. 526. 

Though unable, from the very limited number of their cases, to settle 
the question of the propriety of vaccinating children, while exposed to the 
variolous contagion, MM. Rilliet and Barthez rather incline to the opinion, 
that the performance of the operation does not prevent the development of 
the disease, and that it causes injurious perturbation in its course; and 
they conclude that we should not vaccinate young and debilitated children, 
which have passed some time exposed to variolous contagion, it being 
better to remove them from its influence, and await the development of the 
normal disease : if this does not come on after a reasonable time, they 
may then be vaccinated. They recommend re-vaccination, as there appears 
abundant proof, that after a certain number of years, the protective powers 
of the vaccination become enfeebled. As regards the period at which 
this should be performed, during the term of life under consideration in 
these volumes, the diminution of its power being as yet very slight, they 
agree with M. Bosquet: "We willingly abandon it to the desires of our 

* "In effect, of 208 children which had been vaccinated, 138 died tuberculous, 70 
non-tuberculous. On the other hand, of 95 children, dying without having been 
vaccinated, 30 only were tuberculous, 65 not so. The same relation is presented 
in children who have neither been vaccinated, nor had variola: of 61 cases in this 
category, 19 died tuberculous, and 42 free from tubercles." — Vol. iii. p. 116. 



1844.] Rilliet and Barlhez on the Diseases of Children, 157 

patients, unless the sudden appearance of an epidemic furnishes a plausible 
pretext for greater instance." 

Premising that, in their opinion, every attempt at general abortive treat- 
ment is dangerous in children, MM. R. and B. agree that, when directed 
to certain parts, as to the face, to prevent pitting, &c., it is useful and ad- 
visable. They prefer the use of the emplasirum vigo cum mercurio, 
which is both easy of application, unattended with pain, and, as far as 
their experience goes, invariably successful, when applied before the third 
day, in close contact with the pustules, and continued on until the termina- 
tion of the eruption on the other parts of the body. There is but one 
inconvenience, and it is but a slight one, in its use, and that is, that in five 
instances the authors have met with attacks of hydrargyria arising from it, 
occurring at about the eighth or ninth day of the eruption, and four or ten 
days after the application of the plaster, and consisting of a slight erythe- 
matous or vesicular eruption about the abdomen, pubes, and thighs, lasting 
a few days, and then disappearing with desquamation in large scabs. It 
was attended with no danger, and, in fact, no other symptoms than the 
mere eruption. 

MM. Rilliet and Barthez have a great dread of purgatives in this dis- 
ease, because they would have the effect to remove the constipation which 
they consider the normal condition of the bowels in variola, and which 
should therefore be respected, unless it causes uneasiness and pain by its 
obstinacy, when some slight laxatives may be given. " For ourselves," 
say they, "who know how easily intestinal affections are caused in chil- 
dren, and who have ascertained the existence of follicular development, or 
of an inflammation of the mucous membrane of the digestive organs in a 
good number of cases of variola we have examined after death, we entirely 
reject this method (the use of purgatives,) and we avoid the production of 
diarrhoea in a young variolous patient." Vol. ii. p. 550. Certainly no one 
would desire to provoke diarrhcea in a young variolous patient; but we can- 
not but believe that the very fact of allowing the constipation of the bowels 
to continue will have a tendency to produce the effect it is so desirable 
to avoid, in consequence of the effort nature will make to relieve the bowels 
of such an inconvenience. Is it not, therefore, better and more rational to 
keep the bowels in a soluble state by mild laxatives from the beginning, 
if necessary, than to wait until pain and distension result from neglect, and 
demand their exhibition under circumstances not quite so favourable? 

Much care has evidently been bestowed upon the preparation of the 
following chapter on scarlatina; indeed, the same may with truth be said 
in respect to this whole section of continued fevers, which contains a large 
amount of very useful matter, suggestive of reflection, and replete with 
instruction. Our attention can be given to a few points only, as we have 
allowed this notice to extend much beyond the limits within which it w^as 
intended to have restricted it. The authors remark that there is an evident 
relation between the brightness of the eruption and the freeness of the 
desquamation, and that it is a favourable sign to find this last take place 
very freely, inasmuch as it appears to prevent the development of anasarca; 
at Ici^st, some of the cases in which this complication was observed, were 
attended with but a moderate fall of the epidermis. This would seem to 
fall in with the generally prevalent opinion, that the milder forms of scarlet 
fever, accompanied with but slight eruption, and followed, consequently, 
by but slight desquamation, are most liable to be followed by secondary 
No. XV.— July, 1844. 14 



158 - Review. [Ju^y 

affections. In some of the cases observed by the authors, "two successive 
eruptions of scarlatina appeared; a sort of relapse, rather rare, and which 
should rather be considered a second attack, when an interval of health 
occurs: in these cases the second eruption is generally anormal in its cha- 
racter." Vol. ii. p. 583. 

The pharyngo-laryngitic affection is not essential to scarlatina; for of 
87 cases, 18 had no angina, 37 had it but slightly, 20 severely, and in 12 
no note is found of this lesion. The scarlatinous eruption in the throat is 
an entirely different matter, and should not be mistaken for it. The angina 
may take the grave ulcerous and pseudo-membranous form, this secondary 
inflammation invading the laryngo-tracheal passages, and presenting some- 
times appearances resembling those of pseudo-membranous laryngitis. 
The authors have never observed, even in these cases, the symptoms 
peculiar to croup. As to anasarca, it was observed in about one tifth of all 
the cases between the twelfth and fourteenth days, and of these two-thirds 
laboured under nephritis, manifested by a characteristic lesion, either during 
life or after death. By the results obtained by the authors, the influence 
of cold and of albuminous nephritis in the production of this complication 
is clearly proved; an opinion which agrees with those now admitted by 
the best authorities: indeed, "it is impossible to deny that they often 
concur in the production of those dropsical affections ; the action of cold 
is probably more general than that of nephritis, often precedes it, and is 
thus, at the same time, the cause both of the dropsy and of the disease of 
the kidneys ; and consequently, it is chiefly against its effects that our pro- 
phylactic treatment should be directed." Vol. ii. p. 618. 

Hydrocephalus was rarely met with by the authors, and only in the latter 
stages of scarlatina, manifesting itself by marked nervous symptoms, which 
are liable to be confounded with those due, at an earlier stage of the disease, 
to sanguine congestion, "which complicates this more than any other 
eruptive fever, rendering it promptly fatal." As to the prognosis to be 
made upon the occurrence of cerebral symptoms, indicative of some dis- 
ease of the brain or its membranes, the authors state, "that cases of cure 
have been collected in which the disorders of intelligence were very 
marked; whilst all those patients who, during the first fifteen days of the 
scarlatina, were attacked with convulsions, convulsive movements, con- 
tractions, in a word, symptoms of derangement in the locomotive appa- 
ratus, without exception, died:" a result directly opposite to that obtained 
when these symptoms manifested themselves at a later period, and were 
attributable to serous effusions. Nor is it probable that these acute symp- 
toms of cerebral disturbance are occasioned by meningitis; for, during their 
duration, no diminution of the rapidity with irregularity of the pulse was 
observed, a change so constant in tuberculous meningitis. Vol. ii. p. 623-4. 

Scarlatina and tuberculization are repugnant to each other, according to 
the facts recorded in these volumes. 

"Scarlatina very rarely engenders tubercles; tuberculous children are very 
rarely attacked with scarlatina, which is then anornna] ; children cured of tuber- 
cles contract scarlatina more frequently than the preceding, and in their case the 
eruption may be normal; the tuhercnlous children who contract scarlatina have 
but a small number of crude tubercles, and very rarely softened ones; and in 
these cases the tubercles often manifest a tendency to become soon cretaceous." 
Vol. ii. p. 634. 

The only prophylactic treatment which will probably succeed, is the 



1844.] Rilliet and Barthez on the Diseases of Children, 159 

perfect isolation of those liable to contract the disease, even from the 
attendants on those labouring under it. With the utility of belladonna, in 
small doses, the authors have no experience; still they incline to the opinion 
that it may be serviceable, and recommend its employment, not, however, 
to the neglect of isolation; they justly remark that more positive proofs of 
its efficacy are still wanting, and more explicit information as to its effects, 
and the time for, and mode of, its administration, is much to be desired. 

The last of the continued fevers here studied by the authors, is rubeola. 
They have endeavoured to render the history of this affection complete in 
respect to the influence of its possible complications upon its course, a 
point hitherto much neglected. They show that the course of the normal 
form of this disease is modified by an intercurrent disorder, being differ- 
ently affected in accordance with the nature of the complication and the 
period at which it makes its appearance. Their conclusions are presented 
in the following summary. 

"1st. iVorma/ rubeola commences during the course of good health, and has 
a regular march ; 

"2d. It may be simple, or be accompanied or followed by different accidents, 
which constitute complications. Those of these accidents which are febrile 
never commence before the period of decrease of the eruption ; 

"3d. The anurmal rubeola, which commences during good health, becomes 
anormal in consequence of being complicated by an acute and febrile disease, 
which manifests itself either before the appearance of the eruption, or during its 
period of increase ; 

" 4th. The complications which arise as a sequel to normal or anormal rubeola 
are, either acute inflammatory diseases which keep up the acute febrile move- 
ment, or chronic diseases which change the active fever of rubeola into a hectic 
fever ; 

"5th. Anormal rubeola may arise during the course of another disease; its 
symptoms are then partly confounded with those of this last, and give to the 
patient an aspect which is rarely that of rubeola. Not less serious than the 
other forms, this rubeola may be complicated with the same accidents ; 

" 6th. Finally, rubeola occurs at times during the last days of life ; then com- 
pletely anormal, it scarcely manifests itself but by an eruption, and hastens the 
death of the child." Vol. ii. p. 704. 

The most frequent complication of rubeola — which rarely occur singly, 
several presenting themselves either simultaneously or successively — is 
broncho-pneumonia, this being much more usual than either bronchitis or 
pneumonia alone. The latter, when it occurs, is lobular, with a tendency 
to disseminate itself through both lungs, and to advance to the third degree, 
even to suppuration. It is very rarely lobar. When the pneumonia 
coincides with the commencement of the rubeola, it may, in all proba- 
bility, be considered a distinct disease, and, indeed, it would seem to be 
so; for, say the authors, "it is under such circumstances that we have 
ascertained the existence of lobar pneumonia in rubeola, whilst the pneu- 
monia which arises during the eruption is always lobular." Vol. ii. p. 715. 
Broncho-pneumonia may be developed at three periods, which we will 
name as they most frequendy present it; during the precursory symptoms, 
or the first days of the eruption, during die decrease of this, and after the 
rubeola, as far as the eruption is concerned, is cured. This complication 
is one of the most frequent — if not the most effectual — cause of death in 
measles; scarcely one of four or five attacked with it recover, whilst in 
simple rubeola recovery is the general rule, and even when pneumonia 



160 Review. [July 

alone complicates it, the cures are more frequent than the deaths. Cold is 
certainly the active agent in the production of broncho-pneumonia, and 
should therefore be strictly guarded against. Pharyngo-laryngitis is a 
frequent complication, though the authors are of opinion that where the 
pharyngitic inflammation was observed, it might, and should be ascribed 
to the coincident prevalence of scarlatina. They remark that " when these 
two diseases coincide, the intensity of the pharyngeal and bronchial in- 
flammation is in inverse proportion to the intensity of the afl"ection; each 
usually complicates. Thus, if the scarlatina is most severe, the bronchitis 
is most prominent, while if the rubeolous eruption be most decided, the 
angina will be the most serious affection." Vol. ii. p. 714. 

Next to the pulmonary complications in frequency, are the inflammation 
and softening of the intestines. These alone are rarely mortal, but when 
coinciding with the pulmonary lesions they are very serious. Young 
children are peculiarly liable to this form of the disease, which is easily 
aggravated and rendered active by the improper use of purgatives. "Ru- 
beola," say the authors, "unquestionably favours the development of 
tubercles ; not as frequently as certain pathologists have pretended, but 
suflficiently so to constitute a considerable proportion. Thus, to judge 
from our own experience, of about 11 cases of primitive rubeola, one 
would be followed by the development of tubercles." Vol. ii. p. 729. 

Having thus completed our consideration of the second volume, we find 
that our notice has extended to such a length that we must postpone 
the examination of the third and last volume to a future occasion. It is 
devoted almost entirely to tuberculous diseases and deserves a more care- 
ful analysis, both on account of the importance of the subjects, and the 
manner in which they are handled, than could be given to it in the very 
limited space into which it would be necesisary here to compress it. 



1844.] 161 



BIBLIOGMPHIC.\L NOTICES. 



Art. IX. — Anatomie et Physiologie du Systeme Nerveux de V Homme et des Ani" 
maux Vertebresi ouvrage contenant dcs Observations Pathologiques relatives au 
Systeme Nerveux, et des Experiences sur les Jlnimaux des classes superieures. 
Par F. A. Longet, Laureat de I'Institut de France, (Acad^mie des Sciences ;) 
Docteur en Medecine de la Faculte de Paris; Professeur d'Anatomie et de 
Piiysiologie; Ciiirurgien de la premiere succursale de la Maison Royale de 
Saint Denis; Membre de la Societe Anatomique. Paris, 1842. 2 vols. 8vo., 
pp. 942 and 698. 

The Anatomy and Physiology of the Nervous System of Man and of the Vertebrated 
Animals generally ^ comp^nsing a Series of Pathological Observations in relation 
to the Nervous System^ and a detail of Experiments made upon the higher order 
of Animals. By F. A. Longet, M. D., &c. &c. 

The name of M. Longet is already known to the student of Physiology as 
the author of several very able papers contained in his Memoires de Physiologie 
Experimentale, and in the M^ork before us he presents anew strong claims to 
their favourable consideration. Comprising a full and critical examination of 
the views of those anatomists who have made the structure of the different por- 
tions of the nervous system the special object of their investigations, together 
with an accurate exposition of the various hypotheses that have been advanced 
in relation to its functions, and an analysis of the facts upon which the most 
important of these are respectively based, in order to determine their real value 
and bearing, the present work will have a peculiar interest for every one who 
is desirous of becoming intimately acquainted with the anatomy and physiology 
of this important portion of the animal organism. It is at least calculated, 
by its fulness and general accuracy very materially to shorten their labour in 
the acquisition of what has already been done towards establishing the actual 
structure and functions of the brain and its appendages, including the spinal 
marrow, ganglions, and nerves. 

The two volumes, as M. Longet remarks, contain an analytical and critical 
exposition of whatever of importance has been written in relation to the anatomy 
and physiology of the nervous system. The author has not contented himself 
with a simple digest of the opinions and investigations of others, but has im- 
posed upon himself the laborious and difficult task of submitting those opinions 
and investigations to the test of experiment and observation — the conclusions of 
preceding physiologists being throughout carefully compared with the results of 
his own researches. 

The author, in his investigation of this important branch of physiology, and 
which he appears to have studied with considerable attention, treats, 1st, of the 
development of the nervous system in general ; 2dly, of the distinction of the 
apparatus of sensibility from that of motion; 3dly, of the mode of action of the 
motor and sensitive nerves; 4thly, of the intimate structure of the nervous system; 
5thly, of its chemical composition; Gthly, of the nervous force. This constitutes 
the first part of the work, or that which treats of the general anatomy and physi- 
ology of the nervous system. The second part, devoted to a consideration of the 
special anatomy and physiology of the nervous system, embraces, 1st, the par- 
ticular history of the cerebro-spinal axis; 2d, of the spinal nerves; 3d, of the 
cranial nerves; 4th, of the great sympathetic; and 5th, a parallel between the 
nervous system of the invertebral animals and that of the vertebral. 

Independently of presenting under each of the foregoing divisions and sub- 

14* 



162 Bibliographical Notices. [July 

divisions a very full and accurate account of the numerous facts and deductions 
for which we are indebted to the labours of those who have devoted themselves 
to the investigation of the structure and functions of the different portions of the 
nervous system, the author has endeavoured to test the results derived from 
experiments performed upon living animals by those derived from pathology 
— which constitutes, indeed, one of the most interesting and valuable features in 
his treatise. But, he remarks, we must candidly confess that, if in our study 
of the functions of the spinal marrow and the nervous cords, the results of 
experiments and those of pathology have been in entire accordance, they have, 
on the other hand, appeared not unfrequently to contradict each other when 
the functions of the encephalic mass have been the subject of our inquiry. 

It will readily be perceived by any one tolerably acquainted with the physi- 
ology of the brain, that a large number of conclusions relative to the functions 
of that organ, rigorously deduced from the most exact and decisive experiments 
upon the inferior animals, will not hold true in reference to man, whose brain is 
much more perfectly organized, and in whom, between its different portions, 
there exists a union and consent of action much more intimate than even in 
those animals who in their organization resemble him the nearest. In conse- 
quence of this, it is seldom that in man one portion of the brain can be acted 
upon without the functions of the other portions of the organ becoming soon 
more or less disturbed. 

Consequently, if we admit that the encephalon is composed of a number of 
parts or individual organs, of which each is appropriated to the accomplishment 
of a special act, it will be at once understood why the facts derived from its 
pathological changes have not furnished any other than plausible arguments in 
favour of the attempts that have been made to localize the cerebral organs. 
Nevertheless, so rich in facts is the pathology of the brain, that it is ready to loan 
them for the support of almost any system ; and thus, according to the manner 
in which we proceed in its interrogation, will it conduct to doubt, to error, or to 
truth, in our attempts to determine the functions of the encephalic portion of the 
nervous apparatus. 

It will not be expected that we should attempt a critical examination of the 
views, in relation to the several physiological questions embraced in the present 
treatise, which M. Longet advocates as those legitimately deducible from well 
established facts, nor shall we enter upon the laborious task of presenting an ana- 
lysis of its contents. The chief interest and value of the work consists in the fact 
of its being itself a critical analysis of every thing of importance that has been 
advanced; and of the results of all the more important series of experiments 
that have been undertaken with the view of elucidating the structure and func- 
tions of the several portions of the nervous system. The observations and 
deductions of the author himself are certainly, in the majority of instances, in 
the highest degree, worthy of attention. His labours, however, have been prin- 
cipally directed to the establishment and more complete elucidation, or to the 
refutation, of the views advanced by preceding or contemporary physiologists. 

The views of M. Longet, in regard to the development of the nervous system 
will be understood from the following propositions with which his chapter on 
that subject concludes. They will be found to differ somewhat from those 
taught by many of the leading authorities of the present day, but would appear 
to accord with the results of repeated minute exaniinations of the animal 
organism at the different periods of fcetal life, and with what we know in rela- 
tion to the laws of development and nutrition of the body generally. 

"1st. No known relation exists primitively, in the embryo, between the 
cerebro-spinal axis and the nerves. 

"2d. The peripheral portion of the nervous system is already very apparent 
when the central portion is scarcely perceptible. 

" 3d. In monsters the first is never found to be formed in the absence of the 
latter. 

"4th. The development of the nervous system would seem to take place from 
the circumference towards the centre. 



1844.] Longet on the Nervous System. 163 

"5th. No one of the primitive points of the system can be regarded as a 
centre of irradiation. 

"6th. The nisus formativus organizes each portion of the system in its place: 
there is a succession in their formation; but the one cannot be considered as an 
efflorescence from the other. 

"7th. The gray portion of the nervous matter does not appear to exist pre- 
viously to the white; the contrary would appear to be the fact. 

"8th. The physiological laws which govern the nutrition of the system are 
decidedly opposed to the supposition of the gray matter being the organ by 
which the white is nourished : one solid substance cannot nourish another solid 
substance. 

" 9th. Before acquiring the permanent form which is proper to it, the cerebro- 
spinal axis of man presents, in its successive evolutions, very nearly the dif- 
ferent forms of the same organ in the vertebral animals of the inferior classes." 

The attention of the author appears to have been very particularly directed to 
establish the fact of the distinction of the special agents of sensation from those 
of motion. So far as regards the spinal nerves, the question M. Longet con- 
siders to be completely settled ; but in regard to the encephalon, the question 
still remains in doubt, and we scarcely possess the elements necessary for its 
solution. 

It is impossible not to regard the spinal marrow as a fundamental organ, of 
which the several fasciculi radiate into the encephalic ganglions, and, therefore, 
if we admit as proved that the posterior fasciculi transmit impressions, while 
the anterior transmit the principle of voluntary motion, it would seem rational 
to presume that, in tracing the individual cords of the spinal marrow into the 
brain, we should be able to determine the centre from which emanates the prin- 
ciple of motion, as well as that toward which converge the various impressions 
transmitted by the nerves. Stated in this manner the physiological problem, 
the solution of which has heretofore defied all our investigations, would appear 
to be extremely easy, and to resolve itself into a simple question of descriptive 
anatomy, of which a skilful hand should be able to give, sooner or later, a satis- 
factory exposition. But, as our author very correctly remarks, without denying 
the possibility of so important a result, there are many circumstances which 
augment very materially the difficulties in the way of its being attained. 

"If anatomy demonstrates that each convolution of the brain is provided, 
independently of the gray substance, with two orders of fibres, the one motor 
and the other sensitive, derived from the spinal marrow, pathology, in confirm- 
ing the fact, at the same time shows that in man the lesion of any one of the 
convolutions, no matter which, produces, most commonly, the loss or various 
disturbances of the motor power, and sometimes the abolition or disturbance of 
that of sensation. From this we may perceive all the difficulties which present 
themselves, in determining, by the aid of pathological facts, the central focus of 
sensation or of motion. 

"With respect to vivisections, they are far from presenting, in the question 
before us, a more certain method of investigation. If we remove completely 
the cerebral lobes of a bird we observe it still to walk and to fly; it may even live 
for many months; and if its conjunctiva be touched, it turns away its head; if 
one of its claws be pinched, it withdraws it, &c. From these facts, therefore, we 
should conclude that the brain, properly speaking, is altogether unconnected 
with the functions of sensibility and of motion. 

"If the cerebral lobes and the corpora striata be removed in a rabbit, it is 
still capable of standing and moving, and if its tail be pinched it utters cries; 
the conclusion is, therefore, the same as in the former case. If in the same 
animals the cerebellum be removed, sensibility, although probably perverted, is 
far from disappearing, and the movements of the body, although disordered, 
may still be produced. If, therefore, we depend upon the results of similar 
experiments made on the inferior animals, we cannot regard either the cerebrum 
or cerebellum as the exclusive centre of motion or of sensation. 

" I have, nevertheless, in many instances, produced paralysis of movement in 



164 Bibliographical Notices. * [July 

the opposite side by destroying, even to a slight extent, one of the cerebral 
hemispheres. Every day we observe in man this form of paralysis result, as 
well from the lesions of the cerebrum as from those of the cerebellum. When 
one or other is the seat of disease, sensation itself may, also, be more or less 
deeply affected, which shows how cautious we should be in referring to one 
species of animals, a result obtained in reference to another species." 

The views of M. Longet in regard to the structure and mode of transmission 
and action of the nerves, are in accordance with those of the most authoritative 
of the recent continental physiologists. He teaches that " the force which is 
transmitted by a motor nerve has no action or effect but in the direction of the 
primitive fibres which go to the muscles; that is to say, from the centre to the 
circumference, and never in the opposite direction." And that "the primitive 
fibres of several motor nerves, which unite to form a plexus or nervous trunk, 
exert their force individually throughout their whole length, the excitor force of 
the one never being communicated to the others." 

This proposition, which excludes all idea of analogy between the anastomoses 
of the blood-vessels, and the supposed anastomoses of the nerves, the latter 
being viewed as a simple separation of one or several independent nervous 
fibres from one nervous trunk, in which they had been associated with other 
fibres, to pass to a neighbouring trunk, and along with the fibres contained in the 
latter to proceed to their point of destination, although not admitted by all phy- 
siologists, would appear, however, to be very fully established by the results of 
numerous cautious examinations. It is impossible to conceive, unless we admit 
the entire and comple independence throughout of each primitive nerve, how any 
local nervous action could take place, either when transmitted from theencepha- 
lon to the peripheral organs, or from the latter to the former. 

In the same manner, as in the nervous anastomoses there is simply a juxta- 
position of primitive fibres, arriving from different points, so also in the nervous 
plexus there is merely a juxtaposition, a change of relation between diff'erent 
fasciculi or nervous cords to give place to new combinations. The anastomoses 
as well as the plexuses being destined to concentrate the action of several differ- 
ent nerves upon one organ. 

M. Longet presents a most interesting and instructive view of the structure of 
the different portions of the encephalon — and investigates with much caution 
the various hypotheses that have been advanced in relation to the functions of 
each, with a critical analysis of the facts upon which these hypotheses are respec- 
tively based. In his labours upon these important points we are unable to follow 
him. 

To the views of Gall in relation to the unfolding of the convolutions of the 
cerebrum, M. Longet is decidedly opposed. 

"The idea," he remarks, "of a similar unfolding of the cerebral convolutions 
seems to have suggested itself at an early period to the minds of anatomists, 
judging from the following passage in the discourse of Steno on the anatomy of 
the brain (1688): ' You will find some who would even pass off" the substance of 
the brain for a membrane.' Let this, however, be as it may, it is certain that 
no other author has attached so much importance to the pretended demonstration 
of the unfolding of the convolutions as Gall. The latter considers it to be one 
of his most important discoveries. 

" According to his view each convolution consists of two fibrous layers, 
of which the internal surfaces are only attached the one to the other, by means 
perhaps of a very loose and delicate cellular tissue, without there existing be- 
tween them any positive union or intimate adhesion by the communication or 
reciprocal transmission of fibres from the one to the other." It is upon this 
formation of the convolutions that he predicates the possibility of their expan- 
sion by disease or by art. 

"In hydrocephalus, according to the German anatomist, the two fibrous 
layers of the convolutions are gradually separated from each other, until they 
become absolutely horizontal, in place of vertical. Let us examine the value 
of this argument. Cuvier assures us, that in hydrocephalus, the prominence 
of the convolutions is eff"aced, and that their medullary matter is diminished in 



1844. J Longet on the Nervous System. 165 

thickness, without, however, any unfolding of the convolutions taking place. 
The parietes of the ventricles, he adds, although distended, have the same 
appearance as usual. In the dropsy of the kidneys, the substance of these 
organs becomes distended and thinned, to the extent of causing them to assume 
the appearance of a membrane, without any one having been led to imagine that 
the substance of the kidneys had become unfolded. From his own observations 
M. Cruveiihier also affirms that in hydrocephalus, the convolutions of the brain 
are not unfolded, but atrophied, flattened and compressed one against the other. 
The anatomical phenomena observed in this affection, do not, therefore, con- 
stitute such conclusive proofs in favour of the opinion of Gall, as he has ima- 
gined. With respect to the physiological phenomena — instead of the continued 
integrity and activity of the intellect which Gall asserts that he observed in the 
single example of hydrocephalus he reports, there is, on the contrary, as is noto- 
rious to every observer, feebleness of intellect in those patients who are affected 
with the disease even in a slight degree — resulting from the pressure of the 
effused fluid upon the convolutions, the impediment thus presented to the circu- 
lation through their vessels, and their consequent atrophy. The opposite condi- 
tion—in other words, the preservation of theintellectual functions, — should be the 
state generally observed, and not the exception, if it were true, as maintained 
by Gall, that hydrocephalus, even of considerable extent, is developed without 
any modification taking place in the intimate structure of the hemispheres of the 
brain 'without any forced distension of their fibres,' and in consequence of a 
simple unfolding of their two fibrous layers — in fact, by a change in their di- 
rection, but one, according to Gall, compatible with the free exercise of their 
functions. 

"The argument drawn from the example of the hydrocephalic brain, is not 
the only one which Gall adduces in support of his opinion of the possibility of 
unfolding the cerebral convolutions; — he asserts that he has effected artificially 
what takes place in the disease referred to. Cuvier, in blowing upon a portion 
of one of the convolutions boiled in oil, saw it separate, not only on the median 
line or that of the union of the two pretended layers, but also upon the sides ; a 
phenomenon which is readily explained by the natural division of the white 
matter of the convolutions into an infinite number of laminae, which are now 
admitted to exist instead of the two layers of Gall. 

"It seems utterly useless to detail here the manner in which the latter pro- 
ceeds in unfolding artificially the convolutions of the brain. I prefer to demon- 
strate at once the fatal blow which he has himself given to his own theory. 
The latter, as we have seen, consists simply in pretending that the whole of the 
cerebral hemispheres may be unfolded into a membrane. Now observe the 
words of this author: 'The fibres of these fasciculi, thus spread out in the con- 
volutions, have nut all the same length,- the shortest terminate immediately outside 
the parietes of the ventricles, at the bottom of the anfractuosities ; the longest 
continue further on side by side to the summit of the convolutions. It is thus 
that are formed various prolongations and various depressions (convolutions and 
anfractuosities) according to the greater or less length of the fibres.' By admit- 
ting the entire accuracy of these assertions of Gall, it is very easy to show that 
the unfolding of the whole of the convolutions or the cerebral hemispheres, is 
in the very face of these assertions, a thing absolutely impossible. To demon- 
strate this we may be permitted to make use of a somewhat rude comparison. 
Let us imagine to ourselves a balloon distended by gas, the surface being undu- 
lated by a number of threads of unequal length proceeding from a central stem 
and attached to the internal surface of the portions of the balloon — the longest 
threads proceeding to the summit of the undulations and the shortest to the de- 
pressions between them. Now it must be evident that if we would unfold a 
balloon thus circumstanced, so as to destroy the undulations upon its surface, the 
first thing to be done would be to cut or break the shorter threads — in the same 
manner the pretended unfolding of the brain cannot be effected, but by the rup- 
ture of at least all the shorter medullary fibres — that is, all those which, accord- 
ing to Gall's own description, terminate at the bottom of the anfractuosities." 



166 Bibliographical Notices. [July 

The whole of the chapter which treats of the structure and functions of the 
cerebrum is rich in facts, drawn from the numerous minute and diversified observa- 
tions which this important division of the nervous system has elicited. Of every 
thing known in relation to it and of almost every thing- conjectured in reference 
to the functions of its different parts, M. Longet has given a very interesting and 
satisfactory notice. But we dare not attempt to follow him in his exposition of 
the anatomy and physiology of what he denominates "the chief head and 
governor of the remainder of the cerebro-spinal axis — the throne of the superior 
faculties, which place man in so elevated a rank in creation, and which so 
nobly distinguish him from all other animals." 

The following resume of the researches of M. Leuret upon the comparative 
disposition of the convolutions in the different classes of animals may, perhaps, 
be new and interesting to many of our readers. 

1. The brains of the most part of the mammifera are provided with convolu- 
tions, f 

2. Those of the mammifera in which the convolutions are wanting all apper- 
tain to those orders in which the organization is the least perfect. 

3. The mammifera may be classed according to the similitude of their cere- 
bral convolutions. 

4. The classification founded upon the similarity of the convolutions, brings 
together those animals which resemble each other in their mental faculties, 
while it separates those in which these faculties are different. _ " 

5. The cerebral convolutions present many very distinct types. Nevertheless, 
we are able to follow the transition of one type into another through the inter- 
mediate gradations. 

6. In three animals, the elephant, the maki, and the monkey, the convolutions 
of the brain have an analogy to those of the human brain, and not to that of 
other animals. 

7. The presence and development of the convolutions have no direct relation 
with the volume of the brain; although it is generally the case that the larger 
the brain the more numerous, and especially the more undulated are the convo- 
lutions. 

8. In the fox, the wolf, the dog and the jackal, the convolutions are extremely 
simple. 

9. In the cat, the convolutions are similar in number to those of the preced- 
ing animals, but they are united the one to the other at several points. 

10. In the bear, the coati, &c., they are still more united, and present a num- 
ber of peculiarities in their details. 

11. In the ruminating herbivorous animals the cerebral convolutions are less 
simple and more undulating than those of the carnivora, and resemble, very 
closely, in their general aspect those of the human subject. 

12. The hog and the bear, have each, in a different manner, a brain which 
indicates a state of transition between the carnivora and herbivora. 

13. The brain of the seal approaches in form that of the hog— while the brain 
of the dolphin, of the porpoise, and of the whale approaches that of the herbi- 
vora. 

14. Of all the mammifera, the elephant and the whale have the largest and 
most undulating convolutions; but the elephant is placed above the whale by 
the possession of convolutions which are found also in the monkey and even in 
man. 

15. It is in the mammifera, the most intelligent, that we find the brain the 
most undulated — but this is not true in regard to all the intelligent animals of 
this class. 

16. Neither the presence of the convolutions, their number nor their form 
indicate in any positive manner, the number and extent of the faculties of the 
mammifera. 

17. The extent of the cerebral surface has no necessary relation with the de- 
velopment of intelligence. 

18. According to the general form of the convolutions, the brain of the mammi- 



1844.] Longet on the Nervous System, 167 

fera may be divided into three groups. In the first are placed the convolutions 
without flexure, those which are separated from each other by regular lines, 
straight or curved. These appertain exclusively to the carnivorous mammifera. 
In the second group, are placed the undulating sinuous convolutions, which at 
first view resemble very nearly those of the human brain. These appertain to all 
the solipedia and to all the ruminatia — animals that live solely upon vegetable 
substances. They appertain to the elephant, which is exclusively herbivorous, 
and are found also in the celacea and the annphibia, animals of which some feed 
upon vegetables, but the most part on fish. Finally, in the third group, are 
ranged the family of bears, that of the marten and that of the hog, omnivorous 
animals, the convolutions of whose brains are both sinuous and non-sinuous. 

Upon the labours of M. Leuret our author remarks — 

"That even according to the researches of this gentleman, we cannot avoid 
recognizing a very intimate relation between the presence or absence of the 
cerebral convolutions as an organic condition, and the development of intelli- 
gence. In fact, the brains of the lower order of animals never present any con- 
volutions, while in those of the higher orders they are invariably preseni — and 
in the elephant, of all the animals inferior to man the most intelligent and 
docile, the cerebral convolutions are the most numerous, and approach the near- 
est to those of the human brain." 

M. Longet admits, as a necessary deduction from the most numerous series 
of observations and experiments — a deduction borne out by all the facts in our pos- 
session whether direct or analogical, that in the cerebral lobes especially exist 
all the material conditions of the intellect, of the sentiments and of the instincts; 
that the number and perfection of the intellectual faculties, in the several spe- 
cies of animals as well as in the individuals of the same species, would appear 
to be in direct proportion with the extent of the cerebral surface, which is mate- 
rially influenced by the number and depth of the convolutions; and still fur- 
ther he admits that the doctrine of especial and distinct organs, existing in the 
cerebral hemispheres, appropriated to each faculty of the mind, and to the 
different moral and instinctive qualities, is neither impossible nor improbable. 
He at the same time denies that its truth has as yet been demonstrated, and main- 
tains that all attempts that have been heretofore made to localize the diflerent 
organs of the intellectual, moral, and instinctive faculties have entirely failed. 

The modern phrenological doctrines he rejects, and attempts to show that they 
are entirely unsupported, and even contradicted in many points, by the facts fur- 
nished from the pathological conditions of the brain — from direct experiments, 
as well as by the deductions drawn from comparative anatomy — under this latter 
head his arguments are entirely derived from the memoir of M. Lafargue, a 
notice of which we gave on a former occasion. (See vol. xxiv. p. 168.) 

The anatomy and physiology of the nerves as well encephalic as spinal, are 
considered at great length, and the recent investigations in relation to the true 
structure and functions of each detailed with perfect clearness and accuracy. 

The great sympathetic nerve, as it has been termed, receives, of course, all the 
attention which is demanded by its importance, as the source of innervation to 
the whole of the organs of the circulatory and nutritive systems ; the very 
great discrepancy and confusion in the opinions that have been entertained in 
regard to its true character and office, and the degree of mystery in which almost 
every question in relation to it has been involved by the contradictory results of 
the experiments that have been undertaken with the view of elucidating its char- 
acter and functions. We regret that the limits to which we are restricted will not 
permit us to present a very full analysis of this portion of the work before us. 

M. Longet, in treating of the structure of the great sympathetic, does not hesi- 
tate, as he remarks, to adopt the opinion of Bichat, that it is not a continued or 
independent nerve formed by primitive fibres proper to it alone. 

" 1 have frequently," he declares, " recognized, on the thoracic portion of this 
nerve, after depriving it of its neurilema, that the roots or external branches of 
each ganglion, on arriving at that particular ganglion, divide themselves, within 
■jts substance, or upon its surface into three orders of filaments; the one, ascend- 



168 Bibliographical Notices. ' [July 

ing, unite with the filaments which descend from the ganglion above, the other, 
descending, unite with the filaments which ascend from the ganglion below, 
while the third order of filaments constitute the internal branches or the visceral. 
From this arrangement of nervous filaments there results a continued series of 
nervous loops, presenting, at irregular intervals, masses of gray matter, which 
often insinuates itself even into the external, internal and anastomotic branches 
of each ganglion. Now, the branches which unite together the ganglions, do not 
form a continuous nerve — they merely pass from each pair of cervical, lumbar 
or cervical ganglions to the two pair immediately above and below. Thus we 
regard the trunk of the great sympathetic only as a non-interrupted series of 
anastomotic arcades, which arcades are formed by the union of a certain num- 
ber of cerebro-spinal filaments intermixed with gray matter. 

" Kach ganglion communicates either with the two orders of roots of the 
spinal nerves, or, at the same time, with the cranial nerves of motion and sen- 
sation. 

"We recognize, therefore, in each ganglion, one or more motor and sensitive 
roots, — one or more sympathetic filaments, to unite with the neighbouring gan- 
glions, — and sensitive and motor fibres, which pass to the mucous surfaces, to 
the glandular organs, and to those contractile tissues which act independently 
of the will. 

"It is not demonstrated that any special fibres arise from the ganglionic 
globules." 

After adducing all the facts which demonstrate the composition of the great 
sympathetic to be such as is above described — and showing that sensations are 
conveyed, under particular circumstances, to the encephalon, through its sensi- 
tive fibres, and that its motor action upon the muscles of organic life is incon- 
testably established, M. Longet examines the question as to the sources of acti- 
vity of the great sympathetic. 

He attempts to prove, and we consider that he has succeeded in proving, 
that the great sympathetic, when isolated and deprived of all connection wifh 
the cerebro-spinal apparatus, is totally incapable of fulfilling its important func- 
tions. After citing the facts drawn from direct experiment and from pathology, 
which bear upon this question, M. Longet remarks — 

"These facts are far from confirming the opinion that regards each ganglion 
as a little nervous centre which acts independently of all relation with the cere- 
bro-spinal axis. Nevertheless, I do not believe that we are warranted in denying 
to the ganglionic tumours, so rich in gray matter and in blood-vessels, an active 
co-operaiion as centres of innervation, (the example of the amyelencephalous 
foetuses proves the contrary). We are, however, obliged to admit, that in the 
adult their action alone is insufficient to keep up the functional activity of the 
nerve." 

In the ensuing chapter the facts are adduced which prove that the great sym- 
pathetic and the cephalo-rachidian nervous system reciprocally influence each 
other. For, although these two nervous apparatuses counterbalance each other 
so exactly, that neither encroaches upon the domain of the other — whence results 
the harmony of action that constitutes the state of health — yet, when this 
equilibrium is from any cause destroyed — the action of the one assumes the 
ascendency, and functional disorder or more or less serious disease is the conse- 
quence. Thus, every sudden change occurring in the central organs of the 
nervous system, by reacting upon the fibres of the great sympathetic, is liable 
to produce a diseased action in the organs supplied by the latter with nervous 
influence. On the other hand— 

"An impression somewhat intense, emanating from those organs to which 
the great sympathetic is distributed, may, in its turn, become transmitted to 
the brain or spinal marrow, and give rise to a reaction in those parts of which 
the innervation is derived from the cerebro-spinal nerves. It is thus that the 
irritations of the intestinal canal, in children, give rise to convulsions, that 
eclampsia in many cases follows almost immediately upon the occurrence of the 
first pains of parturition, and that occasionally the accessions of hysterical con- 



i 



1844.] Longet on the Nervous System. 169 

vulsions is announced by severe pains in the uterus, the ovaries, the solar 
region, &c. We may also notice the spasms of the respiratory muscles which 
accompany the act of vomiting-, when the latter is provoked by irritations of the 
intestinal canal, the kidneys, uterus, &c." 

M. Longet denies that the ganglions of the great sympathetic possess a 
power of determining reflex nervous action similar to that of the spinal marrow. 

In regard to the all-important question, why is it that the movements over 
which the great sympathetic presides, are executed independently of, and are 
entirely uninfluenced by the will — M. Longet offers the following solution, as 
that deducible from the composition of the sympathetic, as well as from all the 
facts that have been established in relation to its mode of action ; — 

"When," he remarks, "we study with great care the spinal roots at their 
origin, we recognize, that, among the radicular fibres, anterior as well as poste- 
rior, some are continuous with the white fibres of the spinal cord, while others 
plunge into its gray substance. The first, which proceed with the medullary fas- 
ciculi to the encephalon, and even to the lobes of the cerebrum, are unquestion- 
ably destined, as well as the medullary fasciculi themselves, for the transmission 
of impressions, and of the principle of voluntary motion. With respect to the 
second, which are arrested in the gray substance — so well organized for the 
production and not for the transmission of nervous influence — is it nor, rational to 
regard them as the originating fibres of the great sympathetic — as those which 
derive from the gray matter of the spinal cord the incitation which the latter 
transmits to the ganglionic nervous system 1 From this view it is easy to 
understand the intimate connection between this system and the spinal marrow — 
to explain why the movements effected under the influence of the great sym- 
pathetic are involuntary, and why the centripetal incitation which it transmits 
should be dispersed in the gray matter of the spinal cord, in order to excite the 
production of nervous force without the intervention of the will in any of 
its acts. 

"Let us apply this theory to one of the abdominal ganglions, for example, 
which, the same as all the others, are each traversed by sensitive and motor 
fibres emanating from the gray matter of the spinal cord. An impression is 
made upon the mucous surface of the small intestines, and passes, through the 
ganglionic body, along the sensitive fibres, to the gray matter of the spinal 
marrow. The latter, in consequence of the stimulation thus received, furnishes 
the nervous motive power, which augmented by ihat of the ganglion, is trans- 
mitted, by the motor filaments, to the muscular fibres of the intestines, which in 
consequence react and contract. It is evident that in this case nothing reaches 
the cerebral lobes or the organs of volition. 

"The involuntary movements under the domain of the great sympathetic, 
may be performed with regularity for some time after a part is completely 
separated from the body. The heart removed from the thorax of a living 
animal will still beat for a long time — the contractions of the heart of some 
of the reptiles will continue for many hours after its removal. The persistaltic 
movements of the intestinal canal will also continue after separation from the 
body; and the oviduct of a tortoise has been seen to eject its contents subse- 
quent to its excision. The nervous filaments which penetrate the contractile 
tissues, do not in such cases develope of themselves the nervous force, but allow 
the contractions to take place only during the period necessary to expend the 
nervous power which they held in reserve. 

" If the parts endowed with involuntary motion, as the heart and intestinal 
canal, preserve for some time after they are separated from the body, the type 
of their rhythmic or peristaltic movements, it is therefore evident that this 
type is independent of the brain and spinal marrow, and that it should be referred 
to a current of the nervous principle acting periodically through the grand sym- 
pathetic. In this case, even the ganglionic plexuses and the ganglions them- 
selves are unnecessary to the maintainance of the type of the involuntary move- 
ments. Contrary to the assertion of M. Brachet, I have always observed in the 
mammifera, (dogs, cats, and rabbits) the heart when placed upon the table, to still 
No. XV.— July, 1844. 15 



170 Bibliographical Notices. £July 

contract periodically after 1 have cut away the base with the cardiac plexus and 
ganglionis — that is to say, after the ablation of the auricles on a level with the ven- 
tricles. Miiller makes a similar observation in reference to the heart of the frog. 
It is necessary, therefore, to admit, that the terminal ramifications of the great 
sympathetic may, even after death, (?) regulate the involuntary movements, by 
expending that nervous influence which they receive periodically and with 
more or less rapidity. 

" Another remark may be made in reference to the movements placed under the 
control of the great sympathetic, showing a slight difference between it and the 
nerves of relation. If an irritant, whether chemical, mechanical or galvanic, be 
applied to one of thecerebro-spinal motor nerves, sudden contractions of the parts 
to which it is distributed, are excited, which contractions occur and cease, with 
the rapidity of lightning. But, if the same irritant be applied to either of the 
divisions of the great sympathetic, no motion is produced until after some 
seconds have elapsed, and it does not arrive at its maximum of intensity until 
after the irritant has been removed. Thus, in the one case, the contractions 
commence and cease with the irritation, while in the other, they do not com- 
mence until some time after the irritation has been ex-cited, and. continue after it 
has ceased. These results would seem to prove that the movement of the ner- 
vous principle is slower in the great sympathetic than in the cerebro-rachidien 
nerves, or, in other terms, that the first is not so good a conductor as the latter. 

" Before terminating the study of the peculiarities connected with the move- 
ments under the control of the sympathetic, I may remark, that the most part of 
those also, which are under the influence of the accessory nerve of Willis, are 
equally subtracted from the empire of the will, and that there exist incontestable 
analogies between these two nerves. The experiments of Bischoflf, as well as 
my own, leave no doubt as to the pneumogastric nerve, properly so called, 
being exclusively a nerve of sensation, while the office of the accessory or 
spinal, which anastomoses with it, is alone to preside over the contractions of 
the muscles of the pharynx and larynx, and the muscular membranes of the 
trachea, bronchi, oesophagus and stomach — while it extends its influence even 
to the heart. Now, all are avv^are that the will exerts no influence upon the 
movements of the greater part of these organs — If, we may remark, the great 
sympathetic arises by a number of roots from the whole length of the spinal 
cord, the accessory nerve derives its origin from a portion of the rachidien axis 
of considerable extent (the cervical portion). It therefore does not appear to me 
to be diflScult to refer the analogy in the motive power of these two nerves to the 
analogy which exists between them in regard to the manner in which their origin 
from the nervous centres takes place. My conviction on this point becomes the 
more positive, from the fact that of all the cerebro-spinal nerves, the accessory 
alone presents this uncommon mode of origin, and that it is the only one of 
them that presides over movements subtracted from the influence of the will. I 
may add, that, in galvanizing the mixed trunk of the spinal nerve (the acces- 
sory and pneumogastric,) I have observed, as in the case of the great sympa- 
thetic, that the motive reaction does not take place until after some instants of 
time, and that it does not attain its maximum of intensity until after the irri- 
tating cause has been removed. These observations have been made upon the 
bronchial ramifications, and those of the oesophagus and stomach of large animals, 
as the horse and ox. 

"The accessory nerve of Willis may, therefore, be regarded as establishing a 
transition between the cerebro-spinal nerves and the great sympathetic — on the 
one part, it is distributed as a nerve of motion, to muscles of animal life (those 
of the larynx, &c.) as well as to those of organic life (the contractile coats of 
the bronchi, oesophagus, stomach and heart,) while on the other part its mode 
of origin resembles that of the great sympathetic." 

We could extend our remarks upon the materials embraced in the work of M. 
Longet, to treble the space we have already occupied, as well as multiply our 
quotations from its diflferent chapters, with great satisfaction to ourselves, and to 
the profit, we are convinced., of oiir readers. But our limits will not permit this 



1844..] Foville on the Cerebro- Spinal Newous System. 171 

indulgence — and even if they did, we eould scarcely afford, within a reason- 
able space, any thin^ more than a very general view of the manner in which 
the author has fulfilled his task. 

Without admilting that all the opinions he has emitted in relation to the 
structure and functions of the nervous system are incontrovertible — his work 
may,, nevertheless, with great confidence, be recommended to the particular 
attention of the student of this important portion of physiology. He has unques- 
tionably collected and collated with great industry, and in general with the 
most perfect impartiality, every thing of importance in relation to it, while he 
has arranged his materials in a manner well adapted to communicate clear and 
distinct views upon each of the topics embraced in the general subject of which 
he treats. 

Some very beautiful and interesting lithographic plates accompany the work 
— illustrative of the form and structure of the brain and spinal marrow, the 
form and relation of their several parts and the mode of origin, &c. of the dif- 
fereiat sets of nerves. D. F, C. 



Art. X. — Traite compUt de rAnatomie, de la Physiologie, et de la Pathologie du 
Sysieme Nerveux Cerebrospinal. Par. M. Foville, Medicin en chef de la Mai- 
son Royale de la Charenton, &c. &c. Premiere parte. Anatomie — avec un 
atlas de xxiii planches. 8vo. pp. 676. Paris, 1844. 

A complete Treatise on the Anatomy^ Physiology^ and Pathology of the CerebrO" 
spinal Nervous System. By M. Foville, Physician in Chief to La Maison 
Royale de la Charenton, &c. &c. Part 1st. Anatomy — with a quarto atlas 
containing 23 lithographic plates. 

It is only within a very few years past, that any thing like correct views in 
relation to the structure and arrangement of the different portions of the nervous 
system have been fully developed. Notwithstanding the nervous centres, and 
prineipa] nervous trunks have been made the subjects of repeated and laborious 
investigation, from a very early period, and by the most skilful anatomists and 
physiologists — but slight advances were made, until lately, towards a knowledge 
of their intimate structure. The attention of the investigator, with few excep- 
tions, was almost exclusively confined to the form and superficial appearances of 
the brain and spinal cord, and to the general distribution of the principal nervous 
cords, which have unquestionably been described by the older anatomists with 
great minuteness and accuracy. 

A few of the earlier anatomists made, it is true, considerable advances towards 
determining the arrangement and course of the nervous fibres in the spinal mar- 
row and brain— and had the important facts developed by them been followed up 
with industry and care, the discovery of the real structure of the nervous masses, 
and of the functions of their different parts, as well as of the several classes of 
nerves which pass to and from them, would certainly not have been left to the 
anatomists of the nineteenth century. 

A careful study of the works of Varolius, Sylvius, Willis, Malpighi, Bartho- 
lin, and several of their contemporaries of less note, will show how many of the 
views in regard to the intimate structure and composition of the brain and spinal 
cord, usually referred to as the results of recent investigation", were, in fact, fully 
anticipated by the labours of the anatomists just named — Labours, that in conse- 
quence of their true value either not being fully appreciated, or intentionally 
overlooked, by succeeding cultivators of the same field, were for a time forgot- 
ten, and have now only been recalled, after their importance had been very 
satisfactorily established by minute and repeated examinations of the nervous 
centres, — undertaken, in many instances, evidently without the slightest know- 
ledge that the same work had already been performed. 



172 Bibliographical Notices. [J'^ly 

It is to the labours of Gall and Spurzbeim, that we are mainly indebted for 
the renewed attention that has been paid during a iew years past, to the study 
of the anatomy, and physiolog-y of the cerebro-spinal nervous system, and for 
the very rapid advances that have, in consequence, been made, in perfecting our 
knowledge of this important and truly interesting portion of the animal organism. 
They have indicated with great clearness, the true principles upon which the 
investigation of its intimate arrangement and composition was to be successfully 
conducted ; while, by their writings and oral instructions, as well as by the 
novelty and ingenuity of many of their doctrines, they have given an impulse to 
the more minute and accurate study of every portion of the nervous apparatus, 
which has already been productive of the most important results — and of the 
ultimate fruits of which we can form no correct anticipation. 

The renewed interest with which the anatomy and physiology of the cerebro- 
spinal masses have become invested, has, as might have been expected, given 
birth to numerous publications, of more or less value, in relation to the subject. 
Among these, the treatise of M. Foville will unquestionably command a very 
high rank. The author has devoted many years to the investigation of the 
structure and functions of the nervous system, and under circumstances peculiarly 
favourable to arriving at positive and accurate results. 

The volume before us, which forms the first part of what is intended to be a 
complete and extended treatise on the anatomy, physiology and pathology of the 
cerebro-spinal system in man, furnishes a minute description — founded on the 
personal observations of the author and his friends — carefully compared with 
those of his predecessors and contemporaries in the same field of inquiry — of 
the form, arrangement and superficial appearance of the several portions of the 
encephalic and spinal nervous masses — as well as of their intimate structure 
and arrangement — of the course, arrangement and connection of the nervous 
fibres which enter into their composition, and the relation which exists between 
the several portions of the nervous centres and the nerves which proceed to or 
pass from them. Together with a full account of the cranio-spinal osseous 
envelope of the central nervous masses — more especially directed to establish 
the precise relation which the different portions of the brain bears to the several 
external regions of the skull — as well as to point out more clearly the serious 
evils that result from every species of confinement or compression to which the 
head may be accidentally or intentionally subjected in early infancy. 

To the treatise is prefixed a very full and peculiarly interesting sketch of the 
various opinions that have been entertained by the more distinguished anato- 
mists and physiologists from the earliest periods in relation to the different por- 
tions of the nervous system — embracing a succinct analysis of the principal 
publications that have appeared upon the subject. This historical introduction, 
which is ably and fairly drawn up, presents an instructive and satisfactory view 
of the gradual steps by which the knowledge of the true structure of the ner- 
vous centres has been attained, while it proves, also, the little claims to origi- 
nality possessed by many of the views that have been developed by the labours 
of the more recent investigators. 

Every part of the work bears unquestionable marks of close observation and 
of perfect accuracy in all the more important details— while the drawings by 
which the descriptions of the author are illustrated, surpass in truth, clearness, 
and beauty of execution any of a similar character with which we are familiar. 

The anatomical description of the cerebro-spinal masses by M. Foville, we 
may remark, in conclusion, possesses a character and importance which will 
render its careful study essential on the part of all who would become fully ac- 
quainted with the structure as preliminary to the study of \\\e functions of the 
nervous apparatus, D. F, C. 



1844.] Memoirs of the Medical Society of Observation of Paris, 173 



Art. XI. — Memoires de la Societe Medicate d'' Observation de Paris. Tome deuxieme, 

Paris, 1844. 

Memoirs of tJie Medical Society of Observation of Paris, Second volume. Paris, 

1844. pp. 596. 

More than six years have elapsed since the publication of the first volume of 
these Memoirs; but we must not, therefore, conclude, we are told by the writer 
of the preface of the present volume, M. Valleix, that the labours of the 
society have been either discontinued or remitted. The great object of the so- 
ciety, from the time of its foundation, about twelve years since, has been the 
gradual accumulation of material of undoubted value, which should first be sub- 
jected to a rigid scrutiny, and afterwards analysed with the view of obtaining- 
general results, which could be made known to the profession in the form of 
memoirs, such as those contained in the volume before us, and for the prepara- 
tion of which much time is required. In collecting and comparing facts, the 
assistance of numbers is invoked, and a considerable part of the preface is occu- 
pied in the refutation of some of the objections which have been made against 
the employment of numerical analysis. The best proof of its value is to be 
found in the many valuable results to which it has led, and in the fact that it is 
steadily gaining ground in the estimation of medical men, as evinced by the 
much more frequent appeal to numerical statements, with the view of attaining 
to positive conclusions. But it is not merely in the employment of numbers as 
an assistant in analysis that the Society of Observation has found opponents. 
It has been said that we have already histories of cases in abundance; and in 
reference to a certain kind of histories, this is certainly true. The society, how- 
ever, demands that the cases presented to it should be detailed and accurate, and 
where deficiencies are observed, they are rigidly criticised ; its members are 
constantly reminded of the necessity of the most scrupulous accuracy in the in- 
vestigation of every point, and until the cases reported by them evince a suffi- 
cient evidence of the proper requisites, they are not admitted into its archives. 
The society is of the mind that the observing and reporting of cases, as well as 
their analysis, is a work which demands not only certain mental requisites, but 
a long practical training for its proper accomplishment. Like the experiments 
of the natural philosopher, or the complicated analysis of the chemist, it demands 
for its performance a familiar acquaintance with the objects upon which it is 
employed, in order to inspire that degree of confidence, which is necessary before 
we can employ the data afforded, as the basis of scientific reasoning. Of such 
data the society thinks that there is a great deficiency, which it is of the last 
importance to supply; and in this respect, also, the correctness of its views is 
daily becoming more and more apparent, the silent acknowledgment of it being 
found in the fact, that everywhere there is a tendency to approach the standard 
which the society has erected. Every one, says M. Valleix, feels, in spite of 
himself, that more attention and accuracy must be brought to bear upon the 
study of cases. The society, therefore, finds no reason to relax its eflforts; but, 
on the contrary, every inducement to prosecute its object, which is altogether 
one of utility. Several memoirs are in course of preparation, so that the forth- 
coming volumes will not be so long deferred. The present volume contains four 
memoirs, the first of which is by M. Louis, being an account of the yellow fever 
of Gibraltar of 1828, now first published in the original. A translation by Dr. 
Shattuck having been already published in this country, and reviewed in this 
journal, we shall not further allude to it here. 

The second is by M. Valleix, and entitled, ^'■Besearckes in reference to tJie frequency 
of the Pulse in Newborn Infants^ and in those aged from seven months to six years.'''' 
Before detailing the result of his own experiments, Dr. V. gives a short account of 
the general state of the question, and of what has been done by other experimenters. 
It is generally stated by authors, that the pulse in infancy is very frequent, and that 
this frequency diminishes as individuals advance in life. The mean frequency 

15* 



174 Bibliographical Notices, [July 

in new-born children is usually represented as from one hundred and thirty to 
one hundred and forty; whilst at the age of one year it is reduced to one hun- 
dred and twenty. A few years since Dr. Gorham published in the London Me- 
dical Gazette an account of some experiments, by which he found that the mean 
frequency in the first twenty-four hours after birth was one hundred and twenty- 
three ; from this time to the end of the first week, one hundred and twenty-eight ; 
after which it increased more rapidly, the mean frequency from one to five 
months, being nearly one hundred and forty-nine, whilst from this period to the 
end of the second year it fell to one hundred and thirty, after which it went on 
diminishing. The experiments of our author accord with those of Dr. Gorham. 
in this, that the pulse in very young infants is much less than at the age of six 
months. But Dr. Valleix estimates the absolute frequency within the first three 
weeks considerably lower than has been done by Dr. Gorham, viz., at eighty- 
seven. From the seventh to the twenty-seventh month, he places the mean fre- 
quency at one hundred and twenty-six, which is also rather lower than that found 
by Dr. G. It is to be recollected, however, that in the first series, where the 
pulse was found to be eighty-seven, the children were asleep, a state which is 
shown to have a positive influence in diminishing its frequency. Making allow- 
ance for this circumstance, our author thinks that the mean frequency of the 
pulse in very young children should be set down at between ninety and one 
hundred. The difference between these results, and those of preceding writers, 
he attributes to the circumstance that the latter have not examined the pulse 
when the infant was as near as possible in a state of perfect repose, or properly 
estimated other incidental circumstances capable of influencing the result. Thus 
he found that the least movement, fretfulness, or other mental emotion, sensibly 
increased the number of pulsations. An increase of the temperature of the room 
of a single degree was found uniformly to increase the frequency. Like Dr. 
Guy, our author found that the pulse was more frequent early in the morning 
than later; but as the children were all examined after breakfast, he thinks that 
this result must in a great measure at least be attributed to the influence of the 
morning meal, the acceleration caused by which would diminish as the morning 
advanced. None were examined at a later period of the day, so that it is doubtful 
whether the results before us really confirm those of Dr. Guy or not. The in- 
fluence of sex was found to be very decided, the pulse in girls being considera- 
bly more frequent than in boys. 

Having thus noticed some of the principal results obtained by M. Valleix, 
without, however, entering into detail, or attempting to give the reader any idea 
of the labour which the minuteness and accuracy of the experiments, and the 
estimation of the various influences aflTecling the general result involved, we 
pass on to the third memoir, by M. Ducrest. This is entitled, '•'■Researches in 
reference to a bony production upon the surface of the cranium in women who have, 
died in child-bed.'''' 

This accidental production consisted of a thin layer, which, in its earlier 
stage, was analogous to cartilage, and at a later period presented the consistence 
of bone. It was especially met with on the internal surface of the cranium, at 
its anterior and superior portion, sometimes in patches, which, at a later period, 
became continuous, forming more extensive layers. In the more advanced 
stages, the base of the cranium became the seat of the disease, but was never 
so extensively covered as the vault. It was found in eighty out of two hundred 
and thirty cases of women who had died in child-bed, whilst in the crania of 
seventy-one individuals, under other circumstances, no traces of the lesion were 
met with. It seems, therefore, sufficiently clear that the pregnant or puerperal 
state, or the diseases supervening in the course of the latter, are principal ele- 
ments in its production. The puerperal state alone appears insufficient to ac- 
count for it, for in several, death took place within a few hours after delivery; 
and it seems impossible to suppose, as M. Ducrest observes, that broad cartila- 
ginous plates could have been formed, and become encrusted with earthy salts 
in three hours. The same objection, says M. Ducrest, is in part applicable to 
the supposition, that it was a consequence of the diseases of which the pa- 



1844.] Memoirs of the Medical Society of Observation of Paris. 175 

tients died. Peritoneal inflammation was present in the great majority of cases, 
and iiow far the same epidemic constitution may have been concerned in the 
production of the lesion in question, it seems impossible to determine for vvapt 
of other data with which to institute a comparison. The presence of this matter 
in the cranium does not appear to have influenced materially the course of the 
puerperal disease just mentioned, or to have given rise to any symptoms by 
which the period of its formation could be determined, or even its existence be 
presumed. At present it comes before us in the light of a curious fact deserving 
of attention, but requiring further observation to determine its causes as well as 
the degree of importance which is to be attached to it. M. Ducrest appears in- 
clined to admit that the state of pregnancy may be a principal cause. To settle 
this question, a sufficient number of crania of those who may, from various 
causes, die previous to delivery, should be examined. 

The last memoir is by Dr. Fauvel, and entitled, '•^Researches in reference to 
Suffocating Capillary Bronchitis (^Suffocating Catarrh^ in both Infants and Adults.''^ 
The term Capillary Bronchitis, says our author, is at present employed to desig- 
nate one of the diseases formerly confounded under the title of Suflfocating 
Catarrh. After giving a separate consideration to each of the symptoms pre- 
sented in the cases, twenty-seven in number, upon which the memoir is based, 
M. Fauvel proceeds to give a general description of the onset and course of the 
disease. Eight of the cases were children, and the remainder adults. 

Save in a single instance, it was preceded for a longer or shorter period, by 
an ordinary bronchitis, upon which it was engrafted, sometimes suddenly, at 
others more gradually. Its commencement was marked by excessive dyspncea, 
anxiety of countenance, pain under the sternum, and frequency of pulse. Once 
established, the phenomena of the disease were so characteristic as to give to it 
a peculiar physiognomy. These phenomena are separately described, according 
as they were met with in children or in adults. 

In children the face was pale, with a violet tinge, especially about the lips; 
the eyes seemed prominent, the countenance vv^as extremely anxious, and the 
nostrils much expanded at each inspiration. The respiratory movements weie 
frequent, and the thorax strongly dilated. From time to time the respiration 
became noisy, stertorous, which stertor disappeared as expectoration came on. 
This probably took place about the third or fourth day, except in three cases, 
when it never came on at all ; was painful and small in quantity, the matter 
expectorated being composed of a thick, yellowish-white substance, without air 
bubbles, and of stringy mucus, sometimes frothy and streaked with blood. 
The voice was natural, speech short and broken. The older children com- 
plained of a lacerating pain under the sternum during the cough, and also of a 
sense of weight which prevented respiration. The pulse was very frequent; 
the skin dry, burning, and presenting more or less of the same violet colour as 
the face; the thirst intense; the intellect undisturbed ; the tongue and digestive 
functions but little altered ; the appetite gone, and the bowels mostly consti- 
pated. Such is an abstract of the principal features of the first stage, as given 
by our author, who goes on to say that "the strength of the patient becoming 
exhausted by the constant muscular eflfort to overcome the impediments to the 
entrance of air into the lungs, the respiratory movements became less powerful, 
and even progressively slower, the cough less vigorous, and the expectoration 
more difficult. The respiration became more embarrassed, and more uniformly 
stertorous; the face assumed a dull leaden colour, the violet tinge becoming 
more marked about the lips, cheeks, and over the whole surface of the body. 
The conjunctiva became injected, the look fixed and expressive of extreme 
terror. When the patients were approached they expressed their fear by cries 
and disordered movements. Those among them who were strong enough to sit 
up, avoided lying on the back, and assumed the most singular positions, bend- 
ing themselves forward, lying flat on the belly, or letting the head hang over 
the bed, and sometimes attempting to get down." The pulse became more fre- 
quent and less strong; the heat of skin diminished, its dryness at times giving 
place to perspiration. The restlessness of the early stage gave place to a steady 



176 Bibliographical Notices. [July 

somnolence, in the midst, of which were heard, at short intervals, plaintive 
groans or harrowing screams. Sometimes a fit of coughing or other circum- 
stance would arouse the patient and bring back the violent efforts of the first 
stage, but this was of short duration; the somnolence and stertor returned, and 
so on lill death. Auscultation discovered, in the early stage, a fine, dry, sub- 
crepitant rale throughout the whole or a greater part of the chest; a rale of larger 
size being mixed with the first, opposite the large bronchial tubes. In the 
second stage the fine sub-crepitant rale was still heard at times during the 
cough, but in general had given place to a sort of scraping (raclement) or dry 
mucous rale, or lastly, difl'erent sorts of sonorous rale. The percussion through- 
out was normal, or clearer than natural. 

Such are the principal phenomena of the disease as it presented itself amongst 
children. In adults they were strikingly similar. 

Of the children, seven out of eight died, the duration of the disease in the 
first being between five and eight days. The duration was about -the same 
amongst the adults who died, but the number of deaths amongst them v^as 
much smaller, being ten only out of nineteen. In those who recovered the 
duration was from eleven to twenty days. 

Upon post-mortem examination it was found that, in every case, the air pas- 
sages contained a muco-purulent matter, thick and adherent, which filled up 
almost all the bronchia, from their second division to their capillary extremities. 
Besides, there was found, in four instances amongst the children, a false mem- 
brane lining a part of the bronchial tubes, along with the purulent matter above 
mentioned, and gradually blending itself with it. 

In all cases also, there was a uniform dilatation of the bronchial tubes, either 
general or partial. The mucous membrane was always red, and presented a 
rough appearance, characters which were most marked in the large bronchial 
tubes. 

The pulmonary tissue was generally pale and bloodless, whilst the ramifica- 
tions of the pulmonary artery were found gorged with blood. 

Pulmonary emphysema, occupying especially the upper lobe and border of 
the lungs, was always met with, as well as a gaseous distension of the organs 
to such an extent that they no longer collapsed, but continued to fill the thoracic 
cavity after it had been opened. 

In nine cases, six of whom were children, there were small purulent granula- 
tions scattered through the lungs. In the same number also there were little 
masses of lobular pneumonia. The bronchial glands were swelled, red, and 
friable, in all the children except one, and in two of the adults; but in most of 
the latter their condition was not recorded. 

The other organs of the body, the brain and abdominal viscera, were charac- 
terized by a congested condition, the consequence of the sanguine distension of 
the right cavities of the heart and the whole venous system. 

Our author, having completed his account of the post-mortem appearances, 
goes on to point out that the inflammation of the small bronchial tubes, is the 
principal pathological condition to which the other alterations of the respiratory 
apparatus can be traced. This inflammation was always characterized by the 
presence of the muco-purulent matter above described, which obstructed the 
bronchial tubes, and which, by its retention there, would naturally give rise to 
the dilatation of these latter. The general gaseous distension of the lungs, as 
well as the partial dilatation of the vesicles, is accounted for, Dr. F. thinks, on 
the theory adopted by Laennec in explanation of the latter, with some modifi- 
cations. Dr. F. supposes that in inspiration the thick matter which distended 
the bronchial tubes would be forced towards the periphery, whilst the air which 
reached the pulmonary vesicles could not be forced out during expiration in 
opposition to this plastic matter, " so that at each inspiration the air was com- 
pressed by the column of liquid which retained it. The same thing took place 
to a still greater extent during the fits of coughing; for it must not be forgotten 
that the latter, on account of the narrowness of the glottis, is felt throughout 
the whole lung. Hence it followed that the pulmonary cells, constantly dis- 



1844.] Memoirs of the Medical Society of Observation of Paris. 177 

tended by air, were besides subjected to a force which tended to dilate or rup- 
ture them." This gaseous distension of the cells, by the compression which it 
must exert upon their walls, thus obstructing the capillary circulation, accounts 
both for the bloodless condition of the proper tissue, as well as the distension 
of the pulmonary artery, the right side of the heart and the venous system 
generally. As regards the purulent granulations, our author thinks that they 
result from the purulent matter being forced, under certain conditions, out of the 
capillary bronchia, into the pulmonary vesicles, and are not a direct secretion 
from the latter, as has been supposed by some, whence the name of vesicular 
pneumonia v\?hich has been applied to this lesion. Whether mechanically pro- 
duced, or arising from inflammation of the cells, these purulent granulations are 
in either case acknowledged to be the consequence of capillary bronchitis, and 
liable on the other hand to become surrounded by an engorged orhepatized con- 
dition of the pulmonary tissue, constituting lobular pneumonia, a lesion which 
was never met with in those cases which proved rapidly fatal. 

It is hardly necessary to say that the prominent symptoms, as well as the 
fatal termination, find a ready explanation in the fact of the defective hsematosis 
and in the obstruction to the pulmonary circulation. 

As regards the causes of the disease, it would seem that it is rarely a primary 
affection, in the strict sense of the term, having occurred in every case but one, 
in persons who were already labouring under inflammation of the larger bron- 
chial tubes, which latler may be regarded as a principal predisposing cause. 
The only occasional cause which could reasonably be supposed to have exerted 
any influence, was the state of the atmosphere; the disease having been espe- 
cially met with, in cold and variable seasons. It is probable also that the accu- 
mulation of tlie matter secreted from the larger bronchial tubes, owing principally 
to deficient expectoration, the consequence of debility, may have contributed in 
certain cases to the extension of the inflammation to the capillary tubes. Epi- 
demic constitution also appears to exert a decided influence. At the time when 
the disease was observed at the children's hospital, eruptive fevers were pre- 
vailing in the same wards, and a considerable portion of the cases there met with, 
occurred in the course of, or as a consequence of these affections. In some of 
these cases, too, and in these only, were false membranes found in the bronchial 
tubes, a condition which our author is disposed to refer to the special or malig- 
nant character of the epidemic influence. A similar epidemic influence was ob- 
served during a late prevalence of the disease in the Hotel-Dieu at Nantes. 

We shall pass over the chapters on diagnosis and prognosis, simply observing 
that the disease was much more fatal when it was connected with eruptive and 
typhoid fevers &c., than when it followed a simple bronchitis. 

Treatment. — The loss of blood appears to have been much less efficacious than 
free vomiting, which was generally followed, both in children and adults, by 
decided relief. Ipecacuanha was usually employed. 

Tartar emetic in contra-stimulant doses, and persevered in with a view to this 
eflfect, was entirely inefficacious. Expectorants were resorted to only in the 
cases of adults, and here without any evident good effect. Large blisters to the 
chest, generally on its anterior surface, were often applied in the latter stages of 
the disease, but apparently without good eifect, whilst they were often the 
source of extreme pain to the patients. Sinapisms to the extremities were fre- 
quently repeated in every case. Emollient drinks were prescribed, for which, 
in the second stage of the disease, among adults, an infusion of polygala was 
substituted. 

Having described the treatment and its results, in the cases observed by him, 
our author proceeds to indicate the therapeutic measures which he conceives 
most calculated to fulfil the indications clearly pointed out by a knowledge of 
the pathology of the disease. In the first stage, the great object is to reduce the 
inflammation. For this purpose, the loss of blood, when proportioned to the 
age and strength of the patient, may be demanded, and especially so at the out- 
set; but it must not be forgotten that the effect may be injurious in cases where 
the constitution is debilitated from other causes. At the same time emetics 



178 Bibliographical Notices, [July 

should always be resorted to, and it is from them, Dr. F. thinks, that the great- 
est good is to be anticipated. Sinapisms, frictions and dry cups may be simul- 
taneously employed. If notwithstanding these measures the disease goes on to 
the second stage, oris accompanied from the first, with evidences of prostration; 
the loss of blood is not to be thought of, notwithstanding the difficulty of breath- 
ing, the anxiety, and the violet tinge of the integuments. These symptoms of 
asphyxia are produced, says our author, by a mechanical obstacle to the pas- 
sage of the blood through the lungs, and not by pulmonary congestion. By 
emptying the circulatory system, we do not remove the obstacle, but uselessly 
diminish the strength of the patient. Several of his cases evince the truth of the 
remark of Andral, that immediately after the loss of blood under such circum- 
stances, suffocation augments, the rattles become more marked, and extend from 
the bronchia to the trachea. We must not therefore be imposed upon by the 
symptoms of asphyxia above mentioned, the cause of which is to be found in 
the accumulation of the products of secretion in the bronchial tubes. Our great 
endeavour therefore, should be to facilitate expectoration, with which view 
vomiting is again placed by our author in the first rank. For this purpose, ipe- 
cacuanha alone, in moderate and oft repeated doses, is- recommended; free eme- 
sis being not so much demanded here, as nausea and slight vomiting from time 
to time. His high opinion of the efficacy of emetics in this disease, he enforces 
by an appeal to the authority of Fordyce, Cullen, and other English writers, as 
well as some of his own countrymen. In children it is especially important to 
attend to position. The patient should not be allowed to lie on the back, but 
should be supported in a sitting posture or bent forward, and in every way 
assisted in the expulsion of the expectoration. As the expiratory efforts become 
weaker, both in adults and children, it becomes important to stimulate the mus- 
cular action by appropriate remedies, such as polygala or gum ammoniac, or if 
these fail, the preparations of strychnia, as recommended by Stokes. 

The remaining indication is to diminish the bronchial secretion, in cases 
where its extreme abundance is such, as that even a free expectoration is insuf- 
ficient to disencumber the bronchial tubes. To accomplish this object, the bal- 
samic and resinous preparations, such as tolu and turpentine, would be demanded. 
When a prompt and energetic effect was called for, the balsam copaiva would, 
our author thinks, be especially worthy of a trial. Having never seen any good 
from the use of blisters, but the reverse, he is disposed to discard them in the 
treatment of this affection, especially in the cases of children, where they are 
sometimes the cause of serious difficulty. 

The diet should not be too rigid, but on the contrary when the disease has 
lasted more than five or six days, or from the very commencement, in the case 
of children, or of adults who have been much debilitated, it will be proper to 
support the strength by milk, broth, &c. 

Appended to the above memoir are detailed histories of some of the cases upon 
which it is based, and abstracts of the remainder, which conclude the present 
volume. T. S. 



Art. XH. — 1. Eleventh Annual Report of the Trustees {and the Superintendent) 
of the State Lunatic Hospital, at Worcester, (Mass.) December 1843, pp. 109. 

2. Annual Report of the Board of Trustees of the Massachusetts General Hospital 
{and of the Superintendent of the McLean Asylum for the Lisane) for the year 
1843, pp. 64. 

3. State of the New York Hospital and Bloomingdale Asylum, for the year 1843, 
pp. 28. 

4. The Annual Report of the Physician and Superintendent of the Eastern Asylum^ 
in the city of Williamsburg, Virginia, for 1843, pp. 44. 

5. Annual Report of the Managers of the Lunatic Asylum {Kentucky) for 1843. 



Men. 


Women. 


Total. 


194 


114 


238 


HI 


109 


220 


235 


223 


458 


100 


103 


203 


135 


120 


255 


53 


63 


116 


8 


14 


22 
244-^ 


ler, 




259^ 


, each 




22 

28 



1844.] Reports of Insane Asylums. 179 

6. Twenfy-sevenih Annual Report of the state of the Asylum for the relief of persons 
deprived of the use of their reason. Frankford, 1844, pp. 25. 

7. The Nineteenth Annual Report of the officers of the Retreat for the Insane^ at 
Hartford. 1843, pp. 24. 

8. Sixteenth Annual Report of the President and Directors of the Western Lunatic 
Asylum^ to the Legislature of Virginia.- with the Report of the Superintendent 
and Physician, for 1844. Staunton, 1843, pp. 41. 

The Report of the Massachusetts State Hospital for the Insane, for the past 
year, embodies a greater amount of statistical information than any previous 
publication of the fund that has ever emanated from an institution for lunatics, 
on this side of the Atlantic. We select such items as are of the greatest import- 
ance. The fiscal year of the Hospital commences on the 1st of December. 

Patients in the Hospital at commencement of the year, 
" admitted during the year, - - - - 

" in the Hospital during the year, 

" discharged during the year, - _ . 

*' remaining at the close of the year, 

" discharged, recovered, during the year, 

" died during the year, > . - _ 

Monthly average of patients in the Hospital, 
Daily " •' " " for November, 

Greatest monthly number of admissions, April and June, each 
" " discharges, July, 

The number of admissions, says Dr. Woodward, "has been greater the past 
year than any former year. We have constantly accommodated many more 
than we have rooms, so that the average number has been such as to fill all the 
apartments, and most of the time the infirmaries designed for the sick." More- 
over, there have been ninety-eight applicants who could not be admitted, for 
want of room. " The number of deaths has been large, and yet no great sick- 
ness has prevailed, and few cases of acute disease have proved fatal." 

JVTen. Women. Total. 

Whole number of patients admitted in 11 years, 917 860 1777 

" of patients discharged in 11 years, 713 668 1381 

" of patients discharged, cured, in 11 years, 381 411 792 

" of patients died in 11 years, 75 61 136 

" of cases less than one year in duration, 395 432 827 

" of which were cured or curable, 349 387 736 

" of cases more than one year in duration, 515 429 944 

" of which were cured or curable, 155 157 312 

" single 915, married 687, widows 117, widowers 58, 1777 

The past year, " for the first time since the Hospital was opened, the number 
of married persons admitted has exceeded the number of the single, if we ex- 
cept widows and widowers, (103 to 92,)" "celibacy unquestionably favours 
insanity." 

In regard to the curability of insanity, in its early stages, Dr. W. says:' 
"There are not now half a dozen cases in the Hospital, that entered it as recent 
cases, who have failed to recover, and become incurable and hopeless ; and most 
of those which have left us were complicated with epilepsy, palsy, or such gene- 
ral prostration of health as to render them hopeless, independent of their insanity. 
I think it not too much to assume, that insanity, unconnected with such compli- 
cations, is more curable than any other disease of equal severity; more likely to 
be cured than intermittent fever, pneumonia or rheumatism. If this be true, 
then this department of medical science has kept pace with, or overtaken, others 
which have heretofore been considered quite in advance of it." 

" Of patients under 20 years of age, males do not recover in common propor- 
tions, but females recover favourably. By the table (in the Report) it appears 



180 Bihlio graphical Notices. [July 

that more than two-thirds of the females recover. So, also, of females between 
the ages of 20 and 25, nearly two-thirds recover, while only about 50 per cent, of 
the males recover. The rale of recovery increases till the aaes of 45 and 50, 
when at its maximum both sexes recover in the proportion of from 75 to 86 per 
cent. These results are inexplicable and may not hold true elsewhere, but have 
been constantly presented here. Of 69 females between the ages of 45 and 50, 
fifty-Jive recovered, and on]y fourteen failed to recover." 

In treating of the causes of mental alienation Dr. W. says, " Intemperance 
takes a prominent stand in almost every table of British or American statistics 
of 'cause.' It has ever been considered as first and foremost of influences 
which distract and destroy the nervous system. Delirium tremens arises almost 
solely from this cause. Apoplexy, palsy, epilepsy and other diseases arise from 
it and terminate in insanity. These are the physical causes of insanity which 
arise from intemperance; but it is impossible to say how many of the moral 
causes are more or less connected with this great evil, which not only produces 
pecuniary embarrassments, but domestic afflictions, family troubles, disappoint- 
ments of various kinds, and that poverty which, in Europe and in large cities in 
this country, brings many under the influence of this great calamity." 

If we understand the matter aright, the views of Dr. Woodward and of Dr. 
Brigham of the Utica Asylum are somewhat at variance on this subject; the 
former considering intemperance as, in fact, the true cause of the disease, and 
the latter believing that cause to be the mental anxiety which is the result of 
intemperance. 

Of 28 cases supposed to arise from religious causes, 15 " were attributed to the 
Miller excitement, and much larger proportions are ascribed to the same cause 
in some of the New England institutions." If these cases " were recent, and 
not greatly exhausted, they recovered favourably. Two died from exhaustion 
after the highest excitement, and a few have apparently become hopelessly 
insane." 

In his tables. Dr. W. follows "the old divisions of insanity," but "thinks, 
little of the practical utility of this, or any other mode of classification." " Many 
persons," says he, " who are generally esteemed idiots are congenital insane. I 
have seen many who have active but never rational minds. I have been fre- 
quently visited by a class of persons resembling idiots in some respects, but 
diflering from them greatly in mental development, who had minds capable of 
acquiring knowledge to a certain extent, whose bodies were active and well 
formed, which I believe is never the case with true idiots, and who were capa- 
ble of doing many things well : but they were generally exceedingly mischiev- 
ous, often extremely passionate, and had the animal feelings and propensities 
strongly developed, without the guidance of reason." 

From "classification" Dr. W. glides into the medical Jurisprudence of in- 
sanity, a subject now engaging the attention of physicians, mental philosophers 
and legislators. He says "it may not always be easy to distinguish between 
moral insanity and moral turpitude, but it is as easy as to distinguish between 
sincerity and hypocrisy, or between health and the first rudiments of disease." 
And further, " In all cases of moral insanity there is physical disease, which 
may be detected by a physician conversant with insanity, its precursors and 
concomitants, though it may not easily be discerned by a court or jury, however 
enlightened in the law. The distinction which I would make between moral 
insanity and moral turpitude is, that in the former, some diseased functions of 
organs, more or less intimately connected with the brain and nerves, has pre- 
ceded or accompanies it." 

" I have long thought that the monomaniac should not be held responsible for 
opinions or acts not apparently connected with his delusion. I have held this 
opinion because I do not believe that an important function of the mind can be 
disturbed so as to produce a delusion, without, in some measure, disturbing the 
whole mind and the feelings in some degree. Our experience confirms this, as 
we see daily, in hospitals, that monomaniacs are passionate, impulsive, and 
often extremely irritable. A large class of the homicidal insane are of this cha- 



1844.] Reports of Insane Asylums, 181 

racter." In reference to the question that, if patients or persons labourinjr under 
this type of the disease, with the power of discriminating between right and 
wrong, and a full knowledge and appreciation of their amenability to the law, 
commit a felonious act, whether ihey ought to suffer the punishment prescribed 
for the crime, or be acquitted on the ground of insanity, he says, " Did not Had- 
field (defended by Lord Erskine) know that he was acting contrary to the law 
of the land, when he shot at the king, with a f ^11 expectation that the execution 
of the law would consummate his wishes and designs'? So Hathaway, when 
he struck Richards three blows, one in the name of the Father, one in the name 
of the Son, and one in the name of the Holy Ghost, would not have been deterred 
by any knowledge of the law or its consequences. He supposed that it was his 
duty to obey God rather than man ; he was acting by higher authority than any 
earthly tribunal, — it was a command from Heaven. Hathaway was a monoma- 
niac. So Elmer, wben he received the command to kill the infant in the cradle, 
would not have been prevented by the fear of any human law, when he had re- 
ceived the commands of Heaven to take the life of the child and to slay two 
others. Davis killed Edwards by command of General Washington, whom he 
saw soaring in the air, and from whom he distinctly heard the order. In all 
these cases the mind acts impulsively,- the victim of disease does not stop to con- 
sider at the time, as the rational mind would, the evidence of divine authority. 
The mind is unbalanced, and the antagonizing influences are not brought to bear 
upon it till the deed is done." 

" Monomania is insanity: by it the integrity of the mind is disturbed, and 
after it is fully established, the mind can no more be considered sound, than the 
body can be considered well when severe local disease exists in it. One fact 
goes far to support this view of monomania, which is, that under its influence 
the mind becomes imbecile, and in many cases demented. This would hardly 
be the case if the disease did not, in a greater or less degree, disturb the whole 
brain." 

While on the subject of treatment Dr. Woodward remarks, "The British 
physicians have learned not to bleed in mania, but tlie American physicians 
have not. While I have been writing this sheet a patient has been brought to 
my care, spare, pale and feeble, who has been copiously bled four times in ten days, 
and yet is not the less excited. The maniac has not a condition of the brain 
that requires depletion, but an irritable one, that needs cooling applications, and 
quieting remedies and regimen. Cold water and ice are much more likely to 
remove his excitement than bleeding and starvation. Narcotics will control 
him and make him quiet and rational, while he would grow worse if treated 
with severity, and be less likely to recover." 

Explanatory of the assertion that " insanity frequently seems to be produced 
by insufficient diet," two cases are related, one of a collegiate student and the 
other of a young lady, both of whom were insane, and both had lived abste- 
miously. Under narcotics, tonics and a generous diet they both recovered ; the 
former gained forty pounds of flesh in less than three months, and the latter 
twenty pounds in forty days. 

Dr. Woodward dissents from the opinion of Dr. Jacobi of the Siegburg Asy- 
lum, near Bonn, in Germany, that the two sexes of the insane should be treated 
in distinct establishments. *' The intercourse of the sexes in institutions of this 
kind is as favourable as elsewhere. I would increase rather than diminish it, 
and in the hospital would encourage walks, games, and especially dances, in 
which the intelligent and convalescent patients should be brought together, 
under the guidance of their attendants, and hold free and pleasant intercourse. 
Especially would I have them assemble together for religious worship on the 
sabbath, at singing parties, and other seasons of social enjoyment. The influ- 
ence of the sexes is reciprocal everywhere, and when properly directed, has a 
favourable effect on both." 

A large proportion of the patients at the Worcester Hospital continue to 
work. The profits of the farm and garden, the past year, was nearly 10 per 
cent, of the expenses of the establishment; "this reduces the price of board 
No. XV.— July, 1844. 16 



182 Bibliographical Notices, [J"^y 

25 cents per week, or 13 dollars a year, for each patient. The labour done by 
the patients in other departments, aside from agriculture and horticulture, is as 
much, or probably more, than all the hired help do in these departments, so that 
it may be assumed that the patients of the hospital do as much labour as to do the 
whole work o?i the land, the avails of which are from two to three thousand dollars. 
If the farm could be doubled, another 25 per cent, could be deducted from the 
price of board by the profits which would accrue from it." 

The following- extract exhibits the progress of American asylums. " Eleven 
years ago all the institutions in the United States did not admit annually as 
many patients as have been resident in this hospital the past year, and their con- 
dition, with few exceptions, was far from being good. There were not then 
more than one hundred patients in the New England institutions in a year, 
while now there are more than ^Veen hundred. No other state in the Union 
has made such ample provision for its insane as Massachusetts; having had 
458 in its State Hospital, 271 in the McLean Asylum, and 157 in the Boston 
Lunatic Asylum, in all 886, during the past year; and buildings are now being 
erected for at least 150 more, which will give room for 1036." The buildings 
here referred to are additions to the State Hospital. 

2. The Report of Dr. Bell, of the M'Lean Asylum, is, if we are not mis- 
taken, more voluminous than any by which it has been preceded from the same 
institution. In it are discussed, with great ability, many questions of import- 
ance in regard to insanity and the insane. In accordance with opinions ex- 
pressed some three years since. Dr. B. rejects detailed statistics, restricting the 
jnformation usually given by this method to a few prominent and general facts. 

Men. Women. Total. 

Patients in the asylum at beginning of year, 

" admitted during the year, - - - - 

" in the asylum during the year, - - - 

*' discharged during the year, - - - 

*' discharged recovered during the year, 

" died during the year, > - - - 

" remaining at close of the year, - - - 

Whole number admitted since opening of asylum (1818), 
" " discharged since opening of asylum, 

*' " restored since opening of asylum, 

" " died since opening of asylum, 

No suicide or serious accident has occurred during the year, and although the 
mortality has been greater than in any previous year during the administration 
of Dr. Bell, yet there has been less sickness than usual. The deaths were 
mostly from "lingering and necessarily fatal maladies." 

The following extract shows the completeness of the interior of the buildings, 
and the extent to which the insane may safely be accommodated with the con- 
veniences and luxuries of domestic life. "Over more than half of the galleries 
of the asylum we have introduced carpets, paper hangings, curtains, timepieces, 
looking-glasses, toilet-tables, wash-stands, and articles of mahogany furniture, 
and table furnishings in genteel families. The results of this experiment justify 
the assertion that the amount of damage is less than would occur in an ordinary 
hotel. In the sleeping apartments of these galleries the common swell-beam 
French bedsteads, with toilette-tables and wash-stands of the most fragile con- 
struction, to the extent of accommodating one half our boarders, have replaced 
the strong and peculiar articles formerly deemed essential in an insane institu- 
tion ; and in two or three years use not one has been intentionally destroyed." 

In a general review of the cases, "somewhat exceeding a thousand," which 
have come under his care during his connection with the M'Lean Asylum, Dr. 
Bell says, "the best judgment I can form is, that six out of every ten dis- 
charged, including those considered unfit, those discharged with incomplete 
trial, and those dying prior to the event being determined, have recovered." Of 



81 


50 


131 


75 


52 


127 


156 


102 


258 


79 


47 


126 


43 


20 


63 


12 


6 


18 


80 


54 


134 


8), 


2269 

2135 

1020 

204 





i 



1844.] Reports of Insane Mylums, 183 

those cases which had not existed six months at the time of admission, " cer- 
tainly nine-tenths have recovered." 

"The form of disease which has most frequently occasioned, or rather pre- 
ceded death, has been an almost universal failure of the powers of life, admit- 
ting of no place in the ordinary nosological catalogues, but which is reported as 
exhaustion, marasmus, debility," &c. "The next most usual cause of death, 
with us is epilepsy. Each year proves that this comprises over a third of our 
mortality. For the forms of this disease combined with derangement or imbe- 
cility of mind, our experience forces the painful conclusion that no medical 
agents have the slightest curative, or protractive, or modifying influence." 
"The third most usual precedent of death is a form of cerebral affection, well 
marked in its outward manifestations, but the pathological character of which 
has not been well investigated, as far as I can judge. It, no doubt, is a form of 
inflammation of the brain and its membranes, yet still widely removed from 
common inflammation or phrenitis. The character of the mental aberrations 
is much more analogous to the delirium of typhus, or the advanced stages of 
typhoid fever, than to any ordinary type of mental derangement. The patient 
is rarely violent or furious, has momentary glimpses of recognition of familiar 
persons, but soon relapses into confused, indefinite, indistinct delusions, often 
has great abhorrence of food, from the belief that it is poisoned or uncleanly; 
countenance pale and shrunk, no intolerance of light or sound, frequent, yet 
feeble pulse, with great sleeplessness." "The remaining causes of death 
have been very few, but much diversified. Phthisis has been an exceedingly 
rare affection. I find but two deaths from this cause among the more than 
eighty deaths which are registered." 

"In regard to the curability of insanity in its different manifestations, there 
can be no general rule better established than that this is directly in the ratio of 
the duration of the symptoms." But this rule is inapplicable to those cases 
arising from "sudden organic injury of the brain, manifested by difit of greater 
or less marked decidedness." In puerperal insanity, the patient generally being 
early subjected to treatment, usually recovers. "The recovery, often protracted, 
is always entire; no distortions, weaknesses, or eccentricities of mind are apt 
to be its sequel." Cases of insanity with suicidal propensity, being also gene- 
rally placed under treatment at an early period, "are almost all recoverable." 
In regard to these cases. Dr. B. says, "1 should not, with my experience with, 
the suicidal insane, pay the slightest regard to any promises which they might 
make touching the act." "The form of insanity accompanied with strong sus- 
picions of personal injury threatened, of calumny experienced, of secret enemies 
and analogous hallucinations, and at the same time evincing but little aberration 
in the ordinary outward manner and conversation," is attributed to "a depraved 
personal habit, as its originating or perpetuating cause." " Experience shows 
just enough of recoveries, in such cases, to prevent absolute despair, and no 
more." The proportion of cases arising from the abuse of stimulants, has been 
less at the M'Lean Asylum than at some others. In severe cases the intempe- 
rance was a consequence, not a cause, of the mental disease. "The patient is 
not long in recovering after being subjected to the restraints of an institution." 
The cases of delirium tremens, admitted at the M'Lean under Dr. Bell, "have 
uniformly recovered spontaneously, without the employment of medicinal 
agents." 

Down to the year 1840, that form of derangement named paralysie generale 
by the French, was unknown within the walls of this institution ; but since 
that time "twelve or fifteen well-marked cases have been received." They 
were all but one males, and their delusions have "almost always borne refer- 
ence to immense amounts of money, great power, or some similar exaltation. 
No recovery has occurred among them." 

Dr. Bell suggests the following division of insanity, which might become 
the basis of a method of classification. 

"1st. A form of insanity affecting the intellect; when intense and exalted 



184 JBiblio graphical Notices, [July 

constituting- the excited state of mania; when less aggravated appearing in 

delusions merely, in incoherence or imbecility." 

"2d. Insanity not involving essentially the knowing faculties, as far as the 
conversation of the individual is concerned, but touching the moral sense exclu- 
sively." (Moral insanity.) 

"3d. Insanity consisting in deranged or perverted sensibilities." Several 
pages, at the close of the report, are devoted to the medical jurisprudence of 
insanity. After mentioning the criterion of mental alienation adopted by several 
English legal authorities, he says, "The test of the presence of delusions, and 
the criminal act directly connected with and resulting from the delusions, was 
an apparent step towards the truth. It was a step which does not go far enough; 
it does not reach a long list of cases which every book on insanity details, and 
which every guardian of the insane sees, where the individual may be chaoti- 
cally mad, yet without delusion; cases analogous to that state of mind produced 
by and manifested in intoxication, where the whole passions are running into 
wild confusion, yet not one false idea which could be tortured into delusion. 
Still less does such a definition touch those cases where, under a sudden, unac- 
countable impulse the mother kills her own infant, and months afterwards only 
becomes conscious of her act; still less will it comprise the cases of moral 
insanity, of motiveless propensities to kill for the mere craving for the act; to 
steal irrespective of the value of the thing taken, or its use, and the like, of 
which illustrations exist within almost every one's own knowledge, and which 
no one unprejudiced can doubt, are cases free from moral responsibility, what- 
ever the rules of law may determine." We shall close by extracting the 
remarks upon monomania. 

"In my own observation of even those considered as the purest cases of 
monomania, I have found, on being domiciliated with them, and admitted into 
those recesses of thought and feeling of which the world, uninterested as it is 
in the information, can know little or nothing, that there is uniformly so much 
general aberration of mind, so much more disease than is shown on the surface, 
as long since to induce the belief that no such form of insanity as that mono- 
mania which is so often described and referred to in books, — delusions confined 
to one topic, while the rest of the mind is unimpaired — exists in nature. This, 
too, is not only true as regards monomaniac alienations, but the various partial 
and less obvious forms of insanity, in which, as regards at least criminal respon- 
sibility, the only safe rule is, if insane at all, the subjects are irresponsible in 
all things." 

3. The number of patients remaining in the Bloomingdale Asylum January 
1st, 1843, 

Men. Women. Total. 

Was, 61 49 110 

Admitted during the year 45 40 85 

Whole number 106 89 195 

Discharged and died 52 43 95 

Remaining December 31st, 1843, - - - - 54 46 100 

Of those discharged there were cured - - - 27 22 49 

Died 9 5 14 

Of the whole number in the asylum during the year, there were single 90, mar- 
ried 84; widowers 9, widows 12. 

The causes of death, in those who died, were Asthenia 4, Apoplexy 2, Pa- 
ralysis 1, Phrenitis 3, Mania a Potu 2, Dysentery 1, Phthisis 1. 

The whole number of admissions into this establishment from 1821 to 1843, 
both inclusive, — a period of twenty-three years, — was two thmisand seven hun- 
dred and sixly-nine (2769). Of these, one thousand three hundred and four 
(1304) were cured, and two hundred and sixty -one (261) died. 

"One striking advantage resulting from institutions of this character," says 



Men. 


Women. 


Total. 


57 


36 


93 


23 


19 


42 


— 


— 


-_ 


80 


55 


134 


9 


3 


12 


9 


5 


14 



1844.] Reports of Insane Asylums, 185 

Dr. Wilson, "is the prevention of suicide. This is illustrated by the fact, that 
of the number admitted durincr the year, fifteen iiad strong suicidal propensities ; 
and yet they have been happily preserved from the commission of that crime." 
This report is very brief, and I)r. W. intimates that it will be his last. Since 
its publication, and after having conducted the Bloomingdale asylum with much 
ability for a period of five years, he has retired from the situation, and has been 
succeeded by Dr. Pliny Earle. 

4. The report for 1843, of the superintendent of the asylum at Williamsburg, 
is far superior to that by which it was preceded. 

The number of patients in that institution, Jan, 1st, 1843, 

Was, ----- 

" " admitted in during the year 

" " in the asylum in course of the year 
*' " discharged " " " 
" " died " *' " 

" " remaining Dec. 31st, 1843, - 62 47 109 

The number of cures during the year is not given, but we are informed that 
"from the 1st of July, 1841, to the 1st of July 1843, or during the space of 
two years, 50 patients were received; of this number 24 have recovered, counting 
one case in the institution now convalescing." 

The civil condition of the inmates during the past year, was, single 77, mar- 
ried 47, widowers 5, widows 5. Total 134. 

The report contains an interesting article on " occupation," from which we 
learn that, in the female department of the asylum, there has been ^300, y^^ 
worth of sewing, knitting, &c., performed during the year, exclusive of the 
mending. As illustrative of the utility of occupation, the case is related of a 
coloured woman who was brought to the institution in chains, a condition in 
which she had been for eight or ten years. The chain was removed, she was 
set to work, and is now "generally calm and quiet, and one of the most useful 
patients in the house." 

The products of the garden are valued at ^786, y^^. In the cultivation of th^ 
garden, as well as in the employments furnislied by carpenters' and shoemakers' 
shops, the patients are more or less engaged. 

During the year just elapsed a more judicious and effective organization of 
the institution has been introduced,— the umfurm heretofore worn by the patients 
has been abolished and their clothing improved ; religious services have been 
permanently established, and the old iron gratings to the windows — those pri- 
son-like appendages of horror — have been replaced by iron window-sashes. 

Dr. Gait discusses the subject of Nosology, in reference to insanity, at con- 
siderable length. He says, " we prefer to substitute for the term monomania, 
that oi partial insanity. And we would also take, in the place of mania, the 
term general insanity; for, the whole essential difference between these two varie- 
ties consists merely in the relative number of faculties involved. Tliese two 
divisions should, strictly speaking, be the two great classes into which insanity 
properly falls. But we have added in the table three more! (Dementia, moral 
insanity and mania without delirium); and hence we are to consider the five as 
mere subdivisions of two great orders, which themselves differ but as to the com- 
parative number of the faculties involved." 

En resume, Dr. G. gives the following definitions of his classification. "By 
general insanity we denote those cases in which there are a number of the facul- 
ties involved, but the intellectual derangement is the most prominent : in mania 
without delirium, on the contrary, there is the excitement of mania, but it is the 
feelings which are most prominently disordered. In moral insanity there is 
none of the intense excitement of mania, while the feelings are evidently the 

16* 



186 Bibliographical Notices, [July 

cbaTacteriwStic faculties in a diseased condition. In partialinsanity ^ the number 
of tiie faculties concerned is small, and the most apparent disorder is of an intel- 
lectual character. In dementia^ viewed as incoherence, we have a rapid succes- 
sion of ideas and passions, often without evident cause and devoid of connec- 
tion: considered as fatuity there is a diminution of all the faculties in intensity. 
It is ihe termination of the other forms of insanity." 

From the attention which this subject has received during the past year, and 
the space devoted to it in the reports emanatinor from several of the public insti- 
tutions, we are induced to hope that, eventually, some system of classification 
may be devised which, by being based on truth, and addressing itself forcibly 
to reason, shall prove itself worthy of general adoption. 

5. The report now before us, and coming from the State Asylum of Ken- 
tucky is signed by T. B, Pinkard, S. M. Letcher and J. G. Price, as attending 
physicians to that institution. According to their report, great ameliorations 
have been effected in the asylum during their connection with it. Ameliora- 
tions for which, judging by former accounts, there was sufficiency of room. 

" Since the year 1824," say they, " up to 1843, the average per cent, of deaths, 
per annum, has a little exceeded thirty-nine. During the past year the per 
cent, of deaths has been /our and a small fraction.'''' This truly astonishing 
change is attributed to increased exercise, amusements, &c, " Among the 
patients," says the report, " we found ie^^ who did not use tobacco habitually 
and intemperately, in some form or other, whose brain and nervous system had 
been so powerfully impressed by this peculiar poison, that, had they been exa- 
mined by the most astute [obtuse?] physician beyond the walls of a lunatic 
asylum, would have been pronounced the certain subjects of delirium tremens. 
This practice was therefore interdicted. Tlie result of this law upon the health 
of many, both mental and physical, was truly remarkable. There are now 
those who, a few months since, were pale, emaciated and tottering about as con- 
firmed debauchees, who are comparatively ruddy and robust, and who, according 
to the fixed laws of the animal economy, must have soon perished under the 
destructive influence of this nauseous and disgusting practice. 

Carriages for the patients have been employed, for the first time, during the 
past year. "The male patients, with few exceptions, have been engaged in 
agricultural, horticultural, and some few in mechanical pursuits: the females in 
fl|eedle-work, knitting, w^ashing, and all the little domestic occupations in de- 
Tail." The patients are "fed on the best beef and mutton the market affords" 
and " are seated, in perfect order, at as fine a table as any hotel in Kentucky can 
furnish." And we will warrant that they do it ample justice ! 

Men. Women. Total. 

The number of patients January 1st, 1843, was 79 77 156 

" " admitted during the year - - 56 18 74 



(( 



in the course of the year - - 135 95 230 

discharged and died - - 35 25 60 






Remaining December 31st, 1843, - 100 70 170 

discharged, cured - - - 19 14 33 

" died 7 8 15 

Of the whole number there were single 140, married 60, widowers 10, widows 
20. 

6. We have received from Dr. Worthington, Resident Physician of the Frank- 
ford asylum, the twenty-seventh annual report of that institution, from which 
the following particulars are collected. 

Men. 
In the asylum at the commencement of the year - 25 
Admitted during the year - - - - 24 

Whole number 49 39 88 



Women. 


Total. 


21 


46 


18 


42 



1844.] Reports of Insane Asylums. 18T 

Discharged ------ 36 

Of whom recovered ... - 17 

" died ----- 4 

Of the whole number 58 were single, 26 married, 2 widowers and 2 widows. 

Of those admitted during the year, the ages at the time of first attack, were 
under twenty years 16, from twenty to thirty 12, thirty to forty 8, forty to fifty 
3, fifty to sixty 1, seventy to eighty 2. 

7. By the nineteenth annual report of the Hartford Retreat we learn that this 
institution was under the medical care of E. R. Hunt, M. D., during the interval 
between the resignation of Dr. Brigham and the election of the present superin- 
tendent, John S. Butler, M. D. 

The statistics of the Retreat for the medical year of 1842-3 are as follows. 
Number of patients at commencement of year . 89 

" admitted during the year, Men 50, Women 33=83 

"Whole number *' « - - - 

Discharged " " - 

Of whom were recovered 
*' died 

8. From this well-composed and appropriate report by Dr. Stribling, we collect 
the following information in regard to the Medical History of the Staunton 
Asylum during the year 1843. 

Men. Women. Total. 
Patients in the Asylum at the commencement of tbe 

year, 

Patients admitted during the year, 

Whole number, ------ 

Discharged, eloped, and died, - - - 

Of whom recovered, - - - 

Died, 

Patients remaining at the end of the year. 

Civil Condition. — Single 96, married 42, widowers 8, widows 6, unknown 3, 
^ge at which Insanity commenced. — Under twenty years, 25 ; from twenty to 

thirty years, 54; from thirty to forty, 33 ; from forty to fifty, 18; fifty to sixty, 

4; sixty to seventy, 3 ; unknown, 18. 

The following table exhibits the admissions, cures, &c., from the 1st of July, 
1836, to 31st of^'December, 1843. 





172 


40 


36 76 


26 


19 45 


4 


2 6 



73 


36 


109 


37 


9 


46 


110 


45 


165 


29 


7 


36 


17 


6 


23 


G 


1 


7 


81 


38 


119 





Admitted. 


Discharged. 


Cured. 


Per ct. of cures 
on admission. 


Per ct. of cures 
on discharge. 


Men 


178 


110 


61 


34 


55 


Women 


80 


52 


33 


41 


63 



Total 258 162 94 36 58 

A large part of the report is devoted to the truly legitimate objects of publi- 
cations of this kind, a lucid exposition of the results of the curative treatment 
and of the advantages furnished by the institution for the accommodation and 
amusement of the insane. He enters into no discussion of theories in regard to 
insanity, neither does he expound the true principles, nor any principles of the 
therapeutics appropriate to the disease. 

We have been informed, (and we are disposed most cordially to concur with, 
him in the opinion) that his reason for omitting these topics are, that an annual 
report, intended for the general reader, and ordinarily more read by the commu- 
nity at large than by members of the profession, is not the proper channel 
through which to convey intelligence of this kind. The public want results of 



188 Bibliographical Notices, [July 

treatment — not the technicalities of physical medication. While we must 
acknowledge that the physician to any asylum for the insane confers a favour 
upon his professional brethren by unfolding to them the practical results of his 
experience, it is a question which we candidly think demands consideration, 
whether such information ought not to be conveyed through the appropriate 
publications, — the medical journals. 

Dr. Stribling enjoys one advantage, upon which both he and his patients may 
well congratulate themselves. "We are permitted," says he, "to retain our 
patients, in the general, as long as we deem their interests to require it." 
Mark the result. "It has been our custom," he continues, "to inquire care- 
fully, from time to time, after the health of those who were once members of 
our household, and we are gratified to report that, of the whole number dis- 
charged as cured, not more than three, so far as we could learn, have relapsed." 
Premature discharges are the grand evil of most institutions. — According to the 
report, the means for moral treatment at the Staunton Asylum, are altogether 
adequate to the wants of the patients, and Dr. S. apparently presides over a 
very happy household. P. E. 



Art. XIII. — ^ Practical Treatise of Midwifery. By M. Chailly, Doctor of 
Medicine, and ex-chief of the Obstetric Clinique of the Faculty of Paris, Pro- 
fessor of Midwifery, Member of the Society of Medical Emulation, &c. &c. &c. 
Illustrated with two hundred and sixteen wood cuts. A work adopted by the 
Royal Council of Public Instruction. Translated from the French, and edited 
by Gunning S. Bedford, A. M., M. D., Professor of Midwifery and the Dis- 
eases of Women and Children in the University of New York. Bvo. pp. 530. 
New York, 1844. 

It may well be questioned whether the very great multiplication of works on 
midwifery that has taken place within a few years is to the advantage of the 
student. The press has, for some time past, poured forth, with amazing rapid- 
ity, a great variety of publications in relation to the obstetric art — from the 
simple manual with its meagre outline of some of the leading principles and 
more important rules of practice, to the profound and erudite treatise in which 
every question connected with the subject is duly considered, minutely examined 
in all its bearings, and amply illustrated. From amid this accumulation of 
works it might be supposed that it would be easy for each one interested in the 
progress of obstetrics, — the student just entering upon his task, as well as the 
practitioner fully absorbed in the duties of his profession, — to select the one 
best adapted to his peculiar wants ; but, in fact, the very multiplicity and varied 
character of the publications from which his selection is to be made, will be 
very apt to puzzle and mislead. Many of the obstetrical works that have 
been recently issued are unquestionably of the highest order, and admirably 
adapted, either as guides to the learner, or as works of reference for the busy and 
experienced practitioner: but it must not be concealed, that there are others, 
of no remote date, which are of a much more doubtful character, as well in refer- 
ence to the authority of the principles and rules of practice taught in them, as to 
their general arrangement and comprehensiveness. 

The work now before us is one of the latest of the practical treatises on mid- 
wifery that have been issued. How far, the question may be asked, is it adapted 
to the wants of the student and practitioner % 

The treatise of M. Chailly comes to us with strong claims to our favour- 
able notice. It is the production of a highly respectable teacher and prac- 
titioner of obstetrics in Paris, — it professes to embody the opinions and rules 
of practice of Paul Dubois, one of the most popular of the French obstetri- 
cians, and finally, it bears the authorization of the Royal Council of Public 



1844.] Chailly on Midwifery, ^ 189 

Instruction of the University of France, as a mannal to he used " in the Facul- 
ties, in the Schools of Medicine, and in the different courses instituted for 
the instruction of Midwives." 

The work is certainly an excellent manual for the use of the young- stu- 
dent, and will prove a useful introduction to the more extended and copious 
treatises on the science of ohstetrics generally, or upon one or other of its sub- 
divisions. The descriptions of the author are, in most cases, sufficiently clear 
and accurate, and his leading and more important practical directions precise 
and judicious. 

The arrangement adopted by M. Chailly is somewhat different from that pur- 
sued by the majority of the writers on obstetrics. Pregnancy is first treated of 
in all its relations; its possible complications, and the means of remedying them 
are then successively considered ; after which follows a similar consideration of 
delivery, in the presentations of the vertex, face, pelvic extremity, and trunk; 
and, finally, the same plan is pursued in relation to the puerperal state, its acci- 
dents and diseases. 

"In this way, pregnancy, delivery — subdivided into four presentations — and 
the puerperal period, form undivided parts, in which the accidents and treatment 
are grouped together, then the manipulations cease to be abstractions, and are 
appropriated to each specific case." 

"This practical arrangement," M. Chailly remarks, "will enable the accou- 
cheur, at one glance, to embrace all the accidents which may occur either during 
pregnancy, in the various presentations of the foetus, or during the puerperal 
period. He will, likewise, have the order in which the indications are to be ful- 
filled." 

" With this arrangement, the author has been enabled to enter into numerous 
small details, which may appear somewhat tedious to the purely scientific, but 
which will be fully appreciated by the practical accoucheur, and which will be 
valued by the pupils themselves." 

It is this attention, on the part of M. Chailly, to the minutias of obstetrical 
practice which, in our estimation, particularly adapts the work before us for a 
guide to the young student in his acquisition of the rules of obstetric practice. 
For although " the small details" alluded to are more easily taught and acquired 
in a course of clinical instruction than through even the most accurate details 
given in books, they are, nevertheless, of sufficient importance to claim some 
attention on the part, more particularly, of the authors of such manuals and trea- 
tises as are intended for the use of students who are unfortunately deprived of 
the opportunities for adequate clinical instruction, — which is still, we regret to 
say, the case with a large number in this country. 

While, however, we accord what we believe to be its due meed of praise to 
the treatise of M. Chailly, we cannot subscribe to the extravagant eulogium be- 
stowed upon it in the preface of the American editor. It certainly cannot, with 
any degree of propriety, be said to " combine all that is new and valuable in ob- 
stetric science.^^ The plan of the work is good ; the doctrines it inculcates are, 
in general, accurate; while it contains the minute details of obstetric practice 
in which most other manuals are deficient; nevertheless, it is neither a com- 
plete treatise of midwifery, nor does it embrace a full and faithful exposition of 
the views of every authoritative writer on all points connected with the prin- 
ciples and practice of the obstetric art; and moreover, were we to enter into a 
more particular examination of each portion of the work, we should feel it our 
duty to call in question the accuracy of some of the views and practical direc- 
tions of the author. 

Upon the whole, even for the use of the young student, we should prefer the 
work of Righy, and for those more advanced we have many in all respects supe- 
rior; while, as a work of reference for the practitioner, the treatise of Churchill 
will be found much more full and satisfactory. 

The two hundred and sixteen wood cuts introduced as illustrations of the 
text, and which, the author assures us, he designed himself, are among the most 
clumsy with which we are acquainted. They certainly do very little credit to 



190 Bibliographical Notices, U^^V 

the author's skill as a draftsman ; and, while they are far from being ornamen- 
tal, they are, in one or two instances, of very questionable accuracy. We doubt 
whether they will be found to render more intelligible to the student the descrip- 
tions and manipulations to which they refer, or to give him very clear ideas of 
the mechanism of labour, or of the mode of applying instruments. 

The notes of the American editor require no particular notice; he might, in 
our opinion, have greatly increased their number, and by so doing have added 
to the value of the work. 

D. F. C. 



Art. XIV. — Second Annual Report of the Legislature^ under the Act of March 
1842, relating to the Registry and returns of Births, Marriages and Deaths in 
Massachusetts. For the year ending May \st, 1843. By John A. Bolles, Sec- 
retary of the Commonwealth. Boston, 1843: 86 pages, 8vo., with additional 
tables. 

In most of the European governments, it is required that exact returns shall 
be made of the marriages, births and deaths, which take place not only in the 
larger cities, but in every section of the country. These, when collated by 
the several officers appointed and paid for the purpose, have placed us in posses- 
sion of the most exact information in regard to the movements of population 
from year to year in different locations, as those are affected by the various 
favourable and unfavourable circumstances to which humanity is exposed. Exact 
knowledge has thus, within a comparatively few years, been substituted for 
speculation and uncertainty, which has led to the enactment of many sanitary 
ordinances and regulations highly advantageous to the public. 

With a very few exceptions, no provisions exist in the United States, out of 
the large cities, for ascertaining the exact number of deaths, births and mar- 
riages. Consequently, the amount of these at any time occurring in the rural, 
or great mass of population, cannot be estimated, and thus no means exist which 
admit of comparisons being drawn between the movements of population in 
town and country, or in distant places. So far as we know, Massachusetts is 
the first of the states to set about correcting this deficiency. In so doing, she 
deserves all praise, as well as for the intelligence displayed by her legislators in 
effecting numerous other important objects, among which we may refer to the 
able geological, agricultural, and trigonometrical surveys, including botanical, 
zoological, and entomological investigations upon all the objects of natural history 
found within the borders of the commonwealth. The report upon "destructive 
insects," so ably accomplished by Dr. Harris, of Boston, comprises, of itself, 
nearly four hundred octavo pages. When the states generally shall have fol- 
lowed the enlightened example of Massachusetts, an amount of data will be 
amassed, from which the most interesting results must be drawn. 

The Act of the Commonwealth passed in 1842, " relating to the registration 
and returns of Births, Marriages and Deaths," makes it the duty of the Secre- 
tary of State to prepare and furnish to the town (township) clerks blank forms 
of returns, in accordance with the details of the act, and to accompany these 
forms with the needful explanations and instructions; and generally to do what- 
ever may be requisite to carry out the objects and provisions of the several laws 
relating to this matter. The annual return must be made by the several clerks 
during the month of May, under a penalty of ten dollars for neglect. The re- 
vised statutes bind citizens to make returns to the clerks of all births, marriages 
and deaths. The form of record of marriages includes the date of marriage, 
names of the groom and bride, ages of each, colour of each, and town (town- 
ship) to which each belonged at the date of marriage. This form of record of 
births, includes the Christian name and surname of child, names of parents, sex 



1844.] Address of the Massachusetts Medical Society, 191 

and date of birth. The form of record of deaths, includes the date of death, 
name of deceased, age, sex, occupation, and cause of death. 

The annual report before us furnishes lists of the towns which made regular 
reports, as well as those which were delinquent, the proportion of those last 
being small. Following these are tabular statements showing in each county the 
population and modes of employment, as per the U. S. census of 1840, and the 
whole number of births, marriages, and deaths returned, for the year ending 
May 1, 1843. Succeeding the general table, are others embracing detailed 
statements in regard to every town, with remarks and an appendix of letters 
from many town clerks, furnishing much minute and interesting information. 
The table showing the aggregate of deaths, births, &c., returned in 1842 and 
1843, makes it manifest, that the operation of the registration act is not yet as 
perfect as could be desired. There is, however, a perceptible improvement 
remarked in the returns for the last year. But notwithstanding the imperfec- 
tions existing, the information and data obtained are of high value. 

Appended to the annual report, is a communication from Lemuel Shattuck, 
Esq., of Boston, a gentleman who has made himself extensively known by his 
investigations of subjects connected with vital statistics. Mr. S. refers to the 
defects existing in the registration laws, and points out the best methods by 
■which these may be corrected. The system proposed by him contemplates the 
accomplishment of two great objects : — First, to preserve the name, and afford 
the means of identifying the connections, and some facts concerning the per- 
sonal history of every person who is born, marries, and dies, in the community. 
Second, To determine how health, life, and longevity, are affected by age, sex, 
condition, and occupation; by climate, season, and place of residence; and by 
the diseases to which, under any circumstances, man may be subject. He then 
adverts to the particular means best calculated to accomplish these several 
objects. His views are founded upon an intimate acquaintance with the mat- 
ter, and a close consideration of the experience and results obtained by those 
who have laboured in the same department abroad, and especially with the 
able documents furnished by the " Registrar-General" of Great Britain, which 
we have frequently had occasion to notice somewhat at length in previous num- 
bers of this Journal. 



Art, XV. — Address to the Members of the Massachusetts Medical Society. Boston, 

March 1844. 

Here we have another evidence of the zeal with which the objects of science 
and useful research are pursued in the Bay State. At the annual meeting of 
the above named society, in May, 1843, a resolution relative to the registration 
of diseases and their existing circumstances and results was adopted, and the 
whole subject was referred to the counsellors for action. A plan was proposed 
by our colleague. Dr. J. D. Fisher, of Boston, upon which the society should 
engage in a series of statistical and other investigations that would be advan- 
tageous to medical science and public hygiene. The pamphlet before us con- 
tains the Report upon Dr. Fisher's plan. 

In pursuing their investigations, the counsellors advert to the influences 
exerted upon the duration of life by locality and occupations, &c. In regard to 
the operations of the last, they observe: — 

" Our knowledge with regard to the influence of trades upon health rests 
almost entirely upon conjecture. The Second Report to the Legislature of 
Massachusetts upon Births, Deaths and Marriages, states, that the average life 
of thirty-five blacksmiths, who died during the last year, w^as fifty-nine years; 
that of ninety-nine carpenters and one hundred and eighteen shoemakers, each 



192 



Bibliographical Notices, 



[July 



forty-eight years; while seven hundred and three farmers enjoyed a life of sixty- 
five years. The duration of life in carpenters, who work abroad and have 
active exercise, when compared with that of shoemakers, who sit and live in 
close rooms, certainly differs from our common notion of the effect of those 
trades upon health, and a more extensive observation may show that the popu- 
lar opinion is correct. It may be that the difference of mortality of men in 
various pursuits is not so much owing to their occupation as to their domestic 
condition. 

♦'There is reason to believe that there is a s^reat difference in the value of life 
in the different conditions of society. The Report of the Poor Law Commis- 
sioners upon the sanitary condition of the labouring classes of England and 
Wales, shows, that while the families of gentlemen, merchants and professional 
men, average a life, in different places, of from thirty-five to fifty years; 
labourers, operatives, mechanics, servants, and others similarly situated, also 
their wives and children, averaged a life of only fifteen to thirty-five years in 
various places. This difference of the value of life is not confined to England 
and Wales — we have obtained an analysis of the ages, and also of the domestic 
and social condition of one thousand seven hundred and sixty-seven persons, 
who have died in Dorchester within the last twenty-seven years. By this it 
appears that the average duration of life in the families, (including father, 
mother and children,) of labourers, fishermen, journeymen mechanics and fac- 
tory operatives, was 27 yrs. 5 mos. 

Mechanics who carry on business on their own account, . 29 " 6 " 
Merchants, capitalists, professional and salary men, amateur 

farmers, » . 33 " 2 «* 

Farmers who own and cultivate their lands, . . . 45 " 8 " 

" This difference is not chargeable to the occupations merely, for it was found 
the most among the little children at their homes, as will be seen in the follow- 
ino" table. 



Periods of life at which death 
took place. 


Number of persons dying in the families of 


Laborers, &c. 


Mechanics. 


Merch'ls, &c. 


Farmers. 


Total. 


Under 2 years - - 
" 5 " ... 
" 20 " - - - 
« 70 " ... 

Over 70 «... 


161 

203 

244 

462 

61 


115 
148 
191 
351 
50 


127 
172 
235 
499 
90 


33 
50 
63 
191 
73 


436 
573 
733 
1503 
264 


Proportion of Deaths at each period to one thousand in each class. 


Perioda. 


Laborers, &c. 


Mechanics. 


Mercht's, &c. 


Farmers. 


Total. 


Under 2 years, - - 
"5 " ... 
"20 " . - , 
"70 " - . - 

Over 70 « - - - 


313 
395 
474 
901 
99 


280 
368 
476 

875 
124 


215 
292 
398 
847 
152 


124 
188 
237 
735 
274 


246 
324 
410 
850 
149 



"This great difference of mortality between the children of the poor and of the 
comfortable farmer, cannot be caused by the employment of the head of the 
family There must be a cause or causes connected with the domestic condi- 
tion or management to produce this discrepancy. But it is yet a question to be 
resolved by farther and wider observation, whether this, although a general fact 
in England and Wales, is here more than a particular fact in regard to Dor- 
chesle". A similar analysis must therefore be obtained of the mortality of many 
towns in all parts of the state, in order to determine whether life is meted out in 



A 



1844.] Address of the Massachusetts Medical Society, 193 

such various proportions to the different classes of society throughout the com- 
monwealth. 

" A decided influence is exerted upon the health and life by the moral charac- 
ter; yet there are no data to determine how much, or in what way this operates. 
The opponents of intemperance talk vaguely and largely of the effects of this 
vicious indulgence upon the health, but they differ widely from each other, 
because they have no well-digested system of facts to build their theories upon. 
We have but one observation, and that a limited one, taken by a physician in 
the course of two years over about six hundred people in a country town of this 
state. They were persons whose habits were known to him, and during the 
period of his observations they were under his sole professional care. He kept 
a careful record of all their attacks and of the duration of their diseases, and 
compared the number of days the intemperate were sick with those of the abste- 
mious. He ascertained that the former were sick and required his attendance 
fourteen percent, each, on an average, more than the latter; i. e., while the tem- 
perate were sick one hundred days, the same nuniber of the intemperate were 
sick one hundred and fourteen days. This is a valuable observation so far as 
it goes; it shows that the alcoholic temperament or habit probably caused all 
the excess of disease of one class over the other. But some very important 
facts were not observed on account of the limited field of observation. The 
differences of fatality of similar diseases in these two classes, and of the ave- 
rage duration of life, may be and probably are greater than that of the quantity 
of actual disease; but a still greater difference, it is believed, would be revealed 
in the infirmities, in the broken constitution and impaired lives of the intem- 
perate." 

The following general observations made by the conjmittee, express the views 
of the leading members of the medical profession everywhere — we mean the 
high-toned and less venial portion, who are always forward in promoting the 
public welfare at the expense of their own immediate interests. 

"The members of this medical society have not only the duty of healing to 
perform, by which they obtain for themselves honour and profit, but they have 
the work of prevention also, by which they may do the greatest amount of good 
to their fellow men. They owe it to the world and to medical science to learn, 
as far as possible, the vital worth of every place, occupation and circumstance, 
as others learn their pecuniary value, and publish this abroad, so that men may 
avail themselves of the best means to obtain a fulness and a length of life. 

"They are happily situated for this undertaking. 

" Implanted as they are in every district and corner of the state — in towns of 
limited extent and well defined by geographical boundaries — and residing among 
an intelligent people who are ever alive to whatever may interest their individual 
well-being, with whose condition, character and relations to circumstances 
affecting health they are familiar, the members of this society have the means of 
ascertaining almost the whole amount, kind and degree of disease, as well as the 
times, circumstances and causes of almost all the mortality within this common- 
wealth. There is then a responsibility for the use of these means, and for 
accomplishing this good, resting upon this society, which ought to be consi- 
dered, and which cannot be thrown upon the people, nor upon the government. 

" For these reasons, and with these facilities, your committee propose, that 
the medical society proceed at once to the investigation of the nosology and 
mortality of Massachusetts, and invite the co-operation of each one of its mem- 
bers to carry on the work. 

"Your committee propose, that a series of tables and questions be printed, 
and sent to each one of its members, respecting the topography and meteorology 
of every place; the characters and condition of the people; the kinds, amounts, 
and issue of disease ; the causes of mortality, and duration of life. 

"That a printed system of nosology be sent to each Fellow, and that all 
returns of disease be made corresponding to it. 

"That each Fellow not only give answers to the queries respecting the topo- 
graphy of his town and district in general terms, but that he also describe the 
No. XV— -July, 1844. 17 



194 Bibliographical Notices, [July 

sanitary condition of the residence of the patient, the time he has lived in it, his 
habits, occupation, &c. 

*' That each Fellow make annual returns of these observations by mail to such 
committee or officers as the counsellors may appoint to receive them. 

"That this committee or officers digest all these returns into one system, and 
print the results in a tabular form, with such descriptions and annotations as 
may be suggested or supplied to them, and distribute the volume, when printed, 
to the Fellows of the society." 

At the meeting of the Medical Society, the report was accepted, and Dr. 
Fisher, of Boston, Dr. Jarvis, of Dorchester, and Dr. Holmes, of Boston, were 
appointed a committee to lay the whole subject beTore the members, and devise 
plans and means to carry the matter into execution. The pamphlet before us 
contains the plan matured by this able committee. G. E. 



Art. XVI. — The Cyclopedia of Practical Medicine. Edited by John Forbes, 
M. D., F.R.S., Alexander Tweedie, M.D., F.R.S., and John Conolly, 
M.D. Revised, with additions, by Robley Dunglison, M. D. Parts 1, 2, 
3, 4, 5, 6 ; Philadelphia, Lea and Blanchard, 1844: pp. 788, 8vo. 

We rejoice that this work is to he placed within the reach of the profession 
in this country, it being unquestionably one of very great value to the practi- 
tioner. This estimate of it has not been formed from a hasty examination, but 
after an intimate acquaintance derived from frequent consultation of it during 
the past nine or ten years. 

The editors are practitioners of established reputation, and the list of con- 
tributors embraces many of the most eminent professors and teachers of London, 
Edinburgh, Dublin, and Glasgow. 

It is, indeed, the great merit of this work that the principal articles have been 
furnished by practitioners who have not only devoted especial attention to the 
diseases about which they have written, but have also enjoyed opportunities for 
an extensive practical acquaintance with them, — and whose reputation carries the 
assurance of their competency justly to appreciate the opinions of others, while 
it stamps their own doctrines with high and just authority. 

Thus, when we say that the articles on tubercular consumption and climate, 
are by Sir James Clarke, — that those on auscultation and exploration are by 
Dr. Forbes, — that most of the articles on the diseases of the lungs and pleura 
are by Drs. Forbes and Williams, — those on the heart by the late Dr. Hope, — 
those on the principal diseases of the digestive organs by Drs. Stokes and 
Todd, — those relative to the diseases of women and children and to pregnancy 
by Drs. Locock, Lee, Marshall Hall, and Montgomery,— those on mental dis- 
eases by Dr. Pritchard,— those on fevers, the exanthemata and cutaneous affec- 
tions by Drs. Tweedie, Gregory, Todd, &c. &c. &c.; it is unnecessary to add 
that these articles present a full and fair representation of the state of Practical 
Medicine at the time they were written. 

Had a// the subjects been entrusted to equally competent persons, this cyclo- 
pedia would have left little to be desired. 

That in a work contributed by so many hands, even with all the control which 
the editors could exercise, there should be sometimes a want of harmony of 
view both as regards pathological and practical points, is a matter of course; 
but we do not conceive that this in the least detracts from its value. The 
medical library would be small into which was admitted those works only 
which harmonize perfectly in all their doctrines; and certainly it would be 
of very little value to the practitioner v^ho should resort to it for aid when beset 
with practical difficulties. Indeed, in the present state of our science, a similar 
work, written by an individual, could not present a perfect harmony in all its 
views, unless this were attained at the sacrifice of truth — by the adopiion of some 
Procustean process, by which, in some cases, the truth should be exaggerated, 
and in others curtailed. So vast are the bounds of medical science, — so many 



1844.] XW^ow^s Pathology and Practice of Medicine. 195 

the tracts within its limits still imperfectly known, whilst the accounts of ex- 
plorers are utterly contradictory and irreconcilable in regard to them, — that 
the life of an individual is far too short to enable him to examine the whole for 
himself, and a medical cyclopedia, written by one person, must therefore neces- 
sarily degenerate into a mere compilation, on many subjects, — a compilation, 
too, in which the compiler must be often incompetent justly to appreciate the 
facts, and his judgment, of course, be valueless. 

The plan, then, of combining the labours of many in the preparation of a 
cyclopedia, appears to be the best that can be adopted, and experience confirms 
this view, for it is the one so successfully carried out in France and Germany in 
their celebrated medical dictionaries and cyclopedias. 

The first six parts of the American reprint, forming the first volume, or one- 
fourth of the whole work, have been published with commendable punctuality, 
and we have no doubt that the whole will be ready within the period promised 
— a year from the appearance of the first No. The judgment of the profession 
will, we are confident, accord with ours as to the great value of this Cyclopedia. 



Art. XVTI. — The Practice of Medicine: a Treatise 011 Special PotJiology and 
Therapeutics. By Robley Dunglison, M. D., Prof. Inst, of Med. &c. in 
JeflTerson Med. Coll., &c. &c. &c. Second edition in two volumes. Phila- 
delphia: Lea& Blanchard, 1844: pp. 1314, 8vo. 

The early call for a second edition of this work, is sufficient testimony that 
it has been an acceptable one to medical students. "• Grateful for this result the 
author has endeavoured to render the present edition still more useful by adding 
whatever of importance has transpired in the short period that has elapsed since 
the first edition was published, and by supplying omissions, which were almost 
inevitable in the first impression of a work in which so many subjects were 
treated of." 



Art. XVIII. — Outlines of Pathology and Practice of Medicine. By William 
PuLTENEY Alison, M. D., F.R. S. E., Fellow and late President of the Royal 
College of Physicians, Edinburgh, and of the Medieo-Chirurgical Society, Ed- 
inburgh; Honorary Fellow of the King's and Queen's College of Physicians of 
Ireland, and of the Royal Medical Society Edinburgh ; Professor of the Prac- 
tice of Medicine in the University of Edinburgh, and one of the Physicians 
in ordinary to her Majesty for Scotland. Philadelphia: Lea & Blanchard, 
1844: pp. 424. 

This elegantly written and philosophical work must become a classic in 
medical literature. Its author filled for some years, with signal ability, the 
chair of Physiology in the University of Edinburgh, from which he has been 
recently elevated to that of the Practice of Medicine, and this volume is designed 
as a manual for students attending his lectures. " In attempting to compress," 
observes Dr. Alison in his preface,." within the limits of a Text-book for Lec- 
tures, the facts which seem to me best ascertained in regard to the nature, pro- 
gress, and symptoms of diseases, and the effects of remedies upon them, it has 
been my object to simplify as far as possible, both the diagnostic marks of dis- 
eases, and the practical rules for their treatment, — dwelling only upon those, an 
accurate knowledge of which may be acquired without much difficulty, and on 
which it has appeared to me in practice, that we can rely with most confidence. 
I have endeavoured to connect these practical rules and directions with as full a 
statement as the limits of such a work will permit, of the grounds of those opi- 
nions, in regard to the causes, the intimate nature, and fatal tendency of diseases, 
which seen) to me, in the present state of our knowledge, to be supported by the 
best evidence; because, notwithstanding all that has been said, and may be 
said, against medical speculation, 1 am fully convinced of the truth of the obser- 
vation of Dr. CuLLEN, that 'at all times the practice of medicine has been, and 



196 Bibliographical Notices, " [July 

still is, with every person, founded more or less upon certain principles esta- 
blished by reasoninor ;' from which it evidently follows, that any one who 
undertakes to teach the practice of medicine must be prepared to explain the 
grounds of his opinions ; as well as to state the facts, and describe the appear- 
ances, on which he is to found his practical precepts." 

The work is divided into three parts. The first is devoted to the considera- 
tion of violent death — to diseases in general and their terminations— the remote 
causes of disease and the means of their prevention, — and the action of reme- 
dies and the evidence of their efficacy. 

In the second part inflammatory and febrile diseases are treated of; and the 
third part is appropriated to the consideration of chronic and non-febrile diseases. 

Dr. Alison is evidently well acquainted with the existinsf condition of medi- 
cal science ; he has not, however, satisfied himself merely with collecting 
medical facts, — he has carefully weighed and selected them — winnowed the 
wheat from the chaff- and in the performance of this task he manifests a calm 
and cautious judgment, and thorough honesty of purpose. 



Art. XIX. — Annates Medico- PsycJiologiques. Journal de PJnafomie^ de la Phy^ 
siologie et de la Fathologie du Systeme Nerveux. Destine pariiculierrneni a 
rcciieillir tous les documens relalif a la Science des Rapports du Physique et du 
Morale a la Fathologie Mentnle, a la Medecine Legale des alienes, et a la Clinique 
des Maladies Nerveuses. Par M. M. les Docteurs Baillarger, Medicin des 
alienes a la Salpetriere. Cehise et Longet. Paris, Janvier, 1844. 

Medico-Psychologic Annals, A Journal of Anatomy ^ Physiology, and the Pathology 
of the Nervous System. Particularly devoted to the collection (f all documents 
connected with the science of Physical and Moral relations, to Mental Pathology^ 
the Medical Jurisprudence (f Insanity, and Clinics on the Diseases of the Nerves, 

If there be any branch of medical science which, during the last half century, 
has made more rapid strides towards perfection than any other, it is that of the 
Pathology and Therapeutics of Insanity. So much attention has been devoted to 
this disorder during the last few years, as to have made room for a periodical in 
which the accumulating knowledge upon the subject may be concentrated. Such 
is the journal, the title of which is at the head of this notice, and which was com- 
menced in January 1843, and is published once in two months, each number 
containing about one hundred and fifty pages. 

The names of the professional men connected with it are a suflicient guarantee 
for its excellence. Among its collaborators are M. Ferrus, general inspector 
of establishments for the insane, and formerly principal physician to the 
Bicetre ; M. Foville, principal physician to the asylum atCharenton; M. Lelut, 
principal physician to the Salpetriere; M. Pariset, honorary principal physician 
to the Salpetriere; M. Mitivie, physician to the Salpetriere; M. M. Voisin and 
Fabret', physicians to Salpetriere and Bicetre; M. Delaye, physician to the asy- 
lum of Toulouse; M. Parchappe, principal physician to the asylum at Rouen; 
M. M. Bottex, Brierre de Boismont & Guislain, all of whom are well known by 
their writings upon mental alienation. The number before us contains the fol- 
lowing articles: 1st, On the Psycho- Physiological Doclrinesof the ancient Hindoo 
Philosophers, by Dr. Thore. 2d. Historical Studies upon Mental Alienation, 
by Ch. Lasegue and Aug. Morel. 3d. Surveillant, Nurse and Guardian, (the 
officers required by law in each public asylum for the insane in France,) by Dr. 
Bouchet, principal physician to the asylum at Nantes. 4th. On Hysteric Para- 
lysis, by Dr. Macario. 5th. Observations on Insanity from Intemperance, by 
Brierre de Boismont. 

These articles are followed by appropriate extracts from other Medical Journals, 
Proceedings of the Academy of Science, and the Royal Academy of Medicine of 
Paris, Notices of Reports of Lunatic Asylums, &c. &c. We extract the follow- 
ing notice of the disease of M. Heinroth, the doctrinal disciple of Stahl, and, of 



1844.] Druitt's Surgery, 197 

late years, the most distinguished supporter of the German or psychological opin- 
ions in regard to the origin, nature, and seat of Insanity. 

A letter fronn Leipsic, (Saxony,) of the first November, 1843, says, "The 
medical sciences have suffered a great loss in the person of M. Heinroth, who 
recently died in this city at the age of seventy years; and who w^as. unquestion- 
ably, one of the most celebrated physicians of mental diseases that Germany has 
ever produced. Heinroth u^as born in Leipsic in 1773. He commenced his 
studies in that city, and completed them in Paris, where he devoted himself par- 
ticularly to the treatment of mental diseases, under the direction of the celebrated 
Pinel, of whom he became one of the most learned students. On returning to 
Leipsic, he was elected to the chair of Mental Disease, (Psychiatric,) which the 
Saxon government created expressly for his occupation, and at the same time 
was made physician to the Insane Hospital of wSt. George in this city. He ful- 
filled the duties of these stations until the time of his decease. 

Heinroth was the first to introduce into Germany the principles developed by 
Pinel and Esquirol in the treatment of the insane, principles which, as is well 
known, consist in the employment of means acting upon the moral rather than 
the physical powers of the patient, and which dispelled the barbarous treatment 
theretofore existing in our country towards the unfortunate beings who are de- 
prived of reason. 

Heinroth translated into German, accompanied by comments and annotations, 
all the works of Pinel, as well as those of Esquirol, with whom he was upon 
terms of intimate friendsivip. He has published a large number of original 
works, which have gained an extensive celebrity. Among them are the " Ma- 
nual of Mental Diseases," '' Guide to Physicians of the Insane," ''Treatise on 
Mental Hygiene," "Manual of Anthropology and Principles of Criminal Psycho- 
logy." We have also, from the pen of M. Heinroth, several popular romances 
and novels, published under the pseudonym of Treumand VVellentreter. M. 
Heinroth was member of nearly all the learned societies, and among them the 
Royal Academy of Medicine of Paris and the Royal Society of London. The 
King of Saxony bestowed upon him the title of "Aulic Counsellor." 

The Medico-Psychologic Annals supplies a long-wanted desideratum to the 
physicians devoted to the treatment of Insanity, and of nervous diseases in gene- 
ral. It is published by Fortin Masson, &c., Place deL'Ecole deMedecine, No. 
1, Paris. P. E. 



Art. XX. — Pathological Hsematology. Jin Essay on the Blood in Dlsrase. By G. 
Andral, Professor of General Pathology and Therapeutics in the University 
of Paris, &c. &c. Translated from the French by J. F. Meigs, M. D., and 
Alfred Stille, M. D., Philadelphia. Lea & Blanchard, 1844: pp. 129, 8vo. 

We have already (see No. 1 of this Journal for April, May, and October, 
1842), given so full a summary of the course of Lectures of M. Andral, which 
form the basis of this work, that we need not again refer to the subject further 
than to recommend the volume before us as embodying in a convenient form an 
account of the very valuable researches of M. A. relative to the condition of the 
blood in disease. 



Art. XXI. — The Principles and Practice of Modern Surgery. By Robert Druitt, 
Surgeon. From the Third London Edition. Illustrated with one hundred 
and fifty-three Wood Engravings. With Notes and Comments, by Joshua 
B. Flint, M. D. — M.M. 8.S., late Professor of Surgery in the Medical Insti- 
tute of Louisville : Svo. Philadelphia, Lea & Blanchard, 1844: pp. 5G8. 

Having already expressed a favourable opinion of this volume in noticing 
(No. for October 1842, p. 439), its first republication in this country, we need 

17* 



198 Bibliographical Notices. ^^^y 

only add now, that the changes, made by the author in his last edition, have 
been judicious, and add much to the value of the work. 

"'J'he additions are solely confined to the practical departments, whilst those 
chapters which treat of theory, or pathological principles, are rendered some- 
what shorter than before." 

The American reprint has been enriched with upwards of sixty wood-cuts, 
not contained in the original, and we are happy to find that in these additions, 
reference has been had to elucidating subjects of ordinary occurrence in the prac- 
tice of the surgeon, — as the nature and })henomena of fractures and dislocations, 
the processes for their reduction, bandaging, &c., — rather than operative displays 
with the knife, which tend to foster a taste for cutting, — the crying evil of sur- 
gery at the present day. 



Art. XXW.— Report on the Progress of Practical Medicine in the Departments of 
Midwifery and the Diseases of Women and Children^ during the years 1842-3. 
By Charles West, M. D., M. R. C. P., Physician to the Royal Infirmary 
for Children; and Physician-Accoucheur to the Finsbury Dispensary. Lon- 
don, 1844 : pp. 37. 

This report, which was originally published in our cotemporary, the British 
and Foreign Medical Review for April last, furnishes a pretty full and very 
well drawn up digest of the facts, which are either new or seem to illustrate 
what was already known, or to confirm the propriety of old modes of practice 
on the general subjects of which it treats during the period mentioned. We 
shall enrich CMir summary with such portions as relate to subjects not already 
noticed. 



Art. XXIII. — Transactions of the New York State Medical Society. Vol. vi. PI. I. 
Albany, 1844: pp. 78, 8vo. 

The New York State Medical Society has, for many years, continued on its 
useful course, exerting always its influence in upholding the dignity of the pro- 
fession, and for the improvement of our science, and annually publishing a col- 
lection of papers, with an abstract of its proceedings at its annual session. 

The volume for the present year contains the annual address by Dr. White, 
on insanity, noticed in the last number of this journal ; Observations on equivo- 
cal generation, by Dr. T. W. B latch ford ; Medico-legal observations on two 
cases in which the crime of murder was charged, by Dr. A. Willard ; Medico- 
legal testimony in a trial for murder by poisoning with arsenic, by Dr. N. S. 
Davis; on the deaths from poisoning, in the city and county of New York, 
during the years 1841, '42, and '43, by Professor J. B. Beck. 

Dr. Beck has obtained from the records of the coroner of New York city and 
county, the following interesting statistics of poisoning, during the years just 
named. 

Eighty-three inquests for poisoning were held — forty-six on males and thirty- 
seven on females. 



Of these there were 


poisoned by 










Arsenic, 


- 




13 


Ardent Spirits, 






Opium, 


. 




8 


Gin, 






Laudanum, - 


- 




39 


Alcohol and Laudanum, 






Paregoric, 


- 




1 


Brandy and Laudanum, 






Solution of Morphia, 


. 




3 


Strychnia, 






Corrosive Sublimate, 


. 




3 


Prussic Acid, 






Colchicum, - 


. 




1 


Phosphorus, 






Sulphuric Acid, 


- 




2 


Carbonate of Potassa, 






Tinct. of Sanguinaria, 


- 


- 


4 






— 


Tartar Emetic, 


- 


- 


1 




Total, 


83 



1844.] Report of Western Penitentiary. 199 

Of the 83, there were, suicides, ----- 50 

Taken by mistake, or through ignorance, &c. - - - 28 
tfnknown, ---_-..-_ 5 

It appears that the two poisons principally used were arsenic and opium in 
some of its forms. 

In the cases of poisoning by arsenic^ the smallest quantity taken was one 
drachm, and the largest two drachms. The shortest time of intervening between 
the taking of the poison and the death, was four hours, the longest two days. 

In the cases of poisoning by opium,ihe smallest quantity was one drachm, the 
largest, one and a half ounce. The shortest lime between the taking and death, 
8 hours, longest, 20 hours. Average time of six cases, 14 hours. 

Of the cases of poisoning by laudanum, the smallest quantity was one drop, 
the largest was IG ounces. The shortest period between taking and death, 2 
hours, the longest, 48 hours. Average of 23 cases, 12 hours. 



Art. XXIV. — Report of the Inspectors of the Western Penitentiary of Pennsylvania, 
for the Year 1843, with the Jiccompanying Documents. Allegheny, 1844 ; pp. 
16, 8vo. 

There were in the Western State Penitentiary on the 1st day of January, 
1843, one hundred and sixty-three prisoners, of whom fifty-nine were males and 
four females, and there were received during the year, seventy, making a total 
of two hundred and thirty-three. There were discharged within the year, eighty- 
five ; sixty-three by expiration of sentence ; sixteen by pardon, and six by death, 
leaving in prison on the 1st of January, 1844, one hundred and forty-eight, of 
whom one hundred and forty-three are males and five females. 

The whole number of prisoners received from the opening of the Penitentiary, 
July 31, 1826, to January 1, 1844, is nine hundred and eighty-five; of these 
eight hundred and six were while males; one hundred and forty coloured 
males; seventeen white females, and twenty-two coloured females. 

On the Isi of January, 1843, there were six prisoners on the sick list, labour- 
ing under the following diseases: one, abdominal dropsy, (subsequently fatal); 
two, functional disease of the liver ; one, chronic diarrhcea, with indigestion ; one, 
scrofula, (discharged subsequently by pardon, or it w^ould probably have termi- 
nated fatally,) and one, neuralgia of stomach. 

The number of deaths during the year were six ;— one, yellow, from apoplexy; 
one, white, from haemoptysis; one, yellow, from nervous fever; one, white, from 
dropsy; one, while, from consumption; and one, black, from scrofula. 

There were under treatment on the 1st of January, 1844, — one, scrofula (deve- 
loped in prison) ; one, bronchitis, (do.); one, partial paralysis, (do.); two, con- 
sumption (entered with the disease); one, scrofula, (do). 

"To satisfy your minds," observes the physician. Dr. J. H. Smith, in his 
report, "as well as the minds of the public, and oppose the arguments urged 
against the system of solitary confinement adopted by this State, as tending to 
engender mental disease and bodily infirmities, I would refer you back for the 
last five years. On the 1st of January, 1839, there were in the prison one hun- 
dred and thirty-four convicts; and the aggregate number received since then, is 
three hundred and ninety-one, in all, five hundred and twenty-five. Out of this 
number, twenty-one deaths have occurred, making an average of four per cent, 
on the scale of fatality. The warden's report will, doubtless, embrace the whole 
number received ;* and so far as the records exhibit, only one case of confirmed 
insanity stands registered." 

* This is stated in the warden's report to be 985. 



200 Bibliographical Notices* \J^^Y 



Art. 'KXY.—Guyh Hospital Reports. Second Series, Nos. 1, 2. April and OctO' 
ber, 1843. Edited by George Hilaro Barlow, M. A., M. D., Physician to 
Guy's Hospital. Edward Cock, Assistant Suroreon to Guy's Hospital. 
Edmund L. Birkett, M. B., Secretary to the Clinical Society. J. H. 
Browne and A. Poland. London, 1843: pp. 572, 8vo. 

The publication of these reports was connmenced in 1835, under the belief 
that they " would prove useful to the pupils of Guy's, by giving a stimulus to 
their clinical pursuits; that they would be acceptable to others, by increasing 
their acquaintance with the practice of one of the leading schools of the me- 
tropolis ; and that they would be generally received as a laudable and proniising 
endeavour to throw open a large emporium of knowledge, hitherto alnnost 
entirely closed." These anticipations seem to have been fully realized. The 
volumes which have appeared comprise a number of admirable papers and mono- 
graphs, by the medical officers of the hospital, with cases and numerous plates. 

In the new series, which commenced in April, 1843, it is proposed to extend 
the scope of the reports, and in addition to the finished treatises, the works of 
individuals, with which the pages of the work have been principally enriched, 
"to illustrate the different classes of disease by the aid of series of reports, col- 
lected within the walls of the hospital, and furnished by the books of the clini- 
cal society; and likewise to apportion a part of each number to the consideration 
of anomalous cases from the same source." 

It is proper to mention that the Clinical Report Society consists of an organ- 
ized body of reporters, taken from among the more advanced pupils. The 
object of the society is to secure an account of every patient admitted ; for 
which purpose the hospital is divided into ten departments — four exclusively 
medical, four exclusively surgical, one mixed, and one obstetrical. The num- 
ber engaged at one time in reporting is about thirty. "The labours of the 
reporters are so regulated, as to demand only such an amount of time as every 
student, at the advanced period of his pupilage required by the society, should 
devote to the practical prosecution of the studies of medicine and surgery; 
whether this be with a view to the qualifying himself for any of the several 
courts of examiners, or to the ultimate, and by far more important object, of fit- 
ting himself for the proper discharge of those duties which, in the pursuance of 
the profession, must devolve upon him. 

" But, in order to secure, as far as possible, the possession of the reports, and 
at the same time indirectly to stimulate the members reporting to the full com- 
pletion of their work, a weekly meeting is held in a room appointed by the 
hospital; where all the eases admitted since the previous meeting are m.en- 
tioned ; the inspections after death, and the operations performed during the 
week, detailed; and any subject of interest in the wards generally noticed ; — so 
that this assembly forms the centre of all the clinical information of the hos- 
pital ; the officers of the society are enabled to detect any falling off among the 
reporters; and these again are here encouraged to ask for the solution of any 
difficulty that may have occurred, or to offer any suggestions regarding the 
cases under their care; while all who attend, either officers or members, report- 
ing or not reporting, have, in these meetings, laid before them an epitome of the 
hospital, where both matter of improvement and interest is sure to be brought 
before their notice." 

The organization of this society is an admirable one, and we regret that we 
cannot give all the details, but we must refer for this to the introduction to the 
first volume of the new series ; at the same time we would urge, with the great- 
est earnestness, upon the students of the large hospitals in this country, the 
establishment of similar societies. 

The two numbers before us contain nineteen papers, with twenty-four plates, 
some of which are finely coloured. 

We shall enrich our journal hereafter with abstracts of some of these valu- 
able papers. 



1844.] 



201 



SUMMARY 

OF THE ,|,, 

IMPROVEMENTS AND DISCOVERIES 

IN THE 

MEDICAL SCIENCES. 

ANATOMY AND PHYSIOLOGY. 

1. Process of Secretion. — "The greater number of the fluids, which constitute 
the basis of the dilterent secretions— such as the g-astric and intestinal juices, 
the saliva, tears, milk, mucus, wax of the ears, fat, &c.— proceed from a gradual 
dissolution of the substance of the very glands which are generally supposed 
to eliminate them. The blood, no doubt, furnishes certain elements for each, 
secreted fluid; but that which constitutes the characteristic constituent of each 
secretion, is the fluid contained in the microscopic cells., which enter into the 
formation of every gland :^ — this fluid is poured out in consequence of either the 
bursting, or the dissolution, of the cellular envelopes. The cells., which along 
with \\\e blastema constitute the parenchymatous substance of glands, are deve- 
loped within the minute secreting canaliculi. When they have attained to a 
certain degree of maturity, they detach themselves from the interior, and are 
carried along in the secreted fluid." — MandPs Manual of Gen, Anat. applied to 
Physiology and Pathology. 

2. Experiments on the action of Strychnia on the Nervous System, and on 
General and Muscular Sensibility. By Dr. Pickford, of Heidelberg. — It results 
from these experiments, 1. That the irritability of the reflex apparatus, both of 
the spinal marrow and medulla oblongata, is extraordinarily increased, so much. 
so, that the slightest contact with the skin produces tetanus. 2. Irritation of 
the abdominal viscera after the destruction of the spinal marrow, is fol- 
lowed by the same effects in a frog in a state of tetanus as in a healthy frog, 
viz., by local contractions. When the medulla oblongata remains entire, the 
local movements in the tetanic frog are greatly augmented in severity and 
extent, but they are regular as in the healthy frog. 3. There is, however, this 
marked difference between the tetanic and the healthy frog, that in the latter a 
strong irritation of the abdominal viscera excites movements of the trunk when 
the medulla oblongata is uninjured, while in the latter such movements do not 
follow the irritation, whether the medulla oblongata be removed or preserved 
entire. Consequently, the effect of strychnia is to augment considerably the 
reflex activity of the cerebral nerves, both those influencing the organs of volun- 
tary and involuntary motion; but it annuls the reciprocal action which the two 
systems of reflexion undergo in the medulla oblongata. — Gaz. Med. de Paris, 
5 Jan., 1844, from lioser et Wunderlich, Archiv. fur Phi/siotogische Heilkunde, 
1843. 

3. Cryptogamic Plant found growing in the Sputa and Lungs of a man who 
laboured under Pneumo-thorax. — Dr. Bennett, in making microscopic examina- 
tions of tubercle, tuberculous sputa, and the lin ng membrane, observed on some 
occasions fragments of tubes, more or less ma:is ed together, which appeared dis. 



202 Progress of the Medical Sciences* [Juty 

tinctly jointed, and which led him to suppose that a vegetable structure must 
occasionally he developed in the matter of tubercle found in the lungs. This 
supposition he afterwards ascertained to be well founded. On examining- the 
sputa of a man in the Royal Infirmary, the most beautiful and regular vegetable 
structure was observed. The individual was labouring under phthisis in its 
last stage, with pneumo-thorax. On examining a drop of the inspissated puru- 
lent-looking matter, discharged by expectoration, with a magnifying power of 
300 diameters, he could perceive long tubes, joined at regular intervals, and 
giving off several branches. They varied in diameter from j^^ to ^^^ of a 
millimetre, and appeared to spring without any root from an amorphous soft 
mass. Interspersed amid these tubes were numerous round and oval globules, 
often T^^-g but generally j^-^ of a millimetre in diameter, which here and there 
assumed the form of bead-like rows. Both the joined filaments and spornies 
were developed in great abundanr-e on the sides of the spit-box containing the 
man's sputa, which, in this situation, were inspissated, and presented a yellow- 
ish coherent and viscous layer. Two days after, the man died, and the left lung 
was found studded with cavities of different sizes, some of which communi- 
cated, hy fistulous openings, with the cavity of the pleura. Several of the 
smaller cavities were partly filled with soft tuberculous matter. On examining 
this matter microscopically thirty-six hours after death, exactly the same appear- 
ances presented themselves as above described. Numerous jointed transparent 
tubes were readily observed, mingled with round or oval corpuscles. Dr. Ben- 
nett has no doubt that these vegetations existed in the man's lungs during life; 
first, because they were apparent in sputa freshly expectorated, and '2dly, because 
they could not have reached such a state of development as has been described, 
in thirty-six hours. They continued to grow and develop themselves in the 
tubercular matter, after the removal of the lungs from the body, as well as in 
the matter discharged before death by expectoration. They resembled the 
Penicillum glaucuai of Link. — Medico- Chirurg. Bev., April, 1844. 

4. Structure of the Lungs. — Mr. Addison (Philos. Trans. 1842), has given an 
account of the anatomy of the minute air-passages, which, while it confirms nearly 
all that Reisseissen observed, is more complete, and very probably true. In 
the foetus the ultimate bronchial subdivisions are tubular; they have a regularly 
branched arrangement, ramifying symmetrically in all directions, and terminating 
■without anastomoses in closed extremities which are generally situated at the 
boundaries of the lobules. But when an animal has respired, the entrance of the 
air into the lungs distends the lobules, and the ultimate bronchial subdivisions 
undergo a great change. The membrane composing each of them offers only a 
feeble resistance to the pressure of the air, and is pushed forwards and distended 
laterally into rounded inflations, forming a series of communicating cells, which, 
meeting on all sides those of the adjoining bronchial subdivisions, are moulded 
by the mutual pressure into various hexagonal and pentagonal forms. These 
distended passages (something like large beaded tubes) Mr. Addison calls 
lobular passages ; and a section of them shows the oval foramina leading from 
cell to cell, which are so conspicuous in a thin layer of inflated and dried lung. 
The air-cells, according to this account, are the inflated parts of the intralobular 
bronchial subdivisions; and those of each lobule form a distinct system, having no 
communication with those of the adjacent lobules, except in the common trunk 
from which the intralobular bronchi of each system are derived. The air-cells 
are from 1-200 to 1-500 of an inch in diameter; and the oval foramina are from 
1-60 to 1-150 of an inch or less in diameter. The blood-vessels lie upon each 
lobular passa!j;e, and between each two of them. — Paget^s Beportf in Brit, and 
For. Med. Bev.^ Jan., 1844. 



1844.] Materia Medica and Pharmacy, 203 



MATERIA MEDICA AND PHARMACY. 

5. New Salt of Mercury and Quinia. — The combination of oxymnriate of 
mercury and tincture of bark has been long known as a remedy for the treat- 
ment of scrofula and enlarged mesenteric glands, also in the treatment of 
strumous ophthalmia. This combination is well known to be unchemical, the 
salt being decomposed by the bark. Mr. R. N. M'Dermott of Dublin, con- 
vinced of the value of a combination of the active principle of the barks with 
salt of mercury — "a combination which, according to the concurring testimony 
of various physicians, accelerates, in a remarkable manner, the constitutional 
action of mercurials, was brought to think that a definite compound might be 
formed in which the bichloride would perform the part of an acid, and the alka- 
loid quinia form the base, and which would combine the thera[)eutic value of 
these two important substances." On trial he found the results were exactly as 
he had anticipated. He obtained a double salt, a proto-chloride of mercury and 
quinia, chemically combined. On subjecting it to the strictest analysis, no 
trace of bichloride could be detected. The intimate combination of the active 
principle of the bark with mercury in the form just indicated, will, in his 
opinion, render it less liable to produce the ill effects of mercury on some con- 
stitutions, while its efficacy as a general rensedy must be much enhanced. He 
anticipates that the combination of these two agents will rarely fail of producing 
a happy result in the diseases of the eye generally, but especially when scrofula 
is present. — Dublin Medical Press ^ March 13, 1841. 

6* Valerianate of Zinc — This new preparation is extolled by some of the 
Italian physicians as a very powerful remedy in several nervous affections. It 
is formed by adding the protoxide of the metal to the vegetable acid to satura- 
tion, and then slowly evaporating the solution. It is administered in the form 
of pill in the dose of one or two grains. In the BuUetino dtlle Sc. Mediche some 
cases of neuralgia successfully treated by it are recorded. 

7. Chloride of Magnesium.— Th\s has lately been recommended as a saline 
aperient by Dr. Lebert. It is said to produce no injurious effect whatever on 
the stomach, and if occasionally it gives rise to any unpleasant sensation, it 
inconveniences less than most other purgatives. It would also seem to favour 
digestion since its purgative action is followed by an icnprovement of the appe- 
tite. The mean dose as an aperient is .32 grammes for an adult, and half that 
quantity for a child of from ten to fourteen years of age. — Frov. Med. and Surg. 
Journ.i 24 April, 1844, from Gaz. Med de Farts. 



MEDICAL PATHOLOGY AND THERAPEUTICS AND PRACTICAL 

MEDICINE. 

8. Best mode of administering Quinine in Intermittent Fevers. — In administer- 
ing quinine between the paroxysms of intermittent fevers, some prefer giving it 
in repeated small doses, others in one large dose shortly after the previous 
paroxysm is over; while a third give the same quantity an hour or two before 
its expected return. 

Dr. Thomas Stratton, of the British Navy, treated a number of cases of 
intermittent fever in 1842, at Port Maitland, Canada, and says that after consi- 
derable observation of the comparative rapidity of cure by repeated small doses, 
or by a single large one, he gives a decided preference to the latter mode. — Ed. 
Med. ^ Surg. Journ.^ April, 1844. 



204 Progress of the Medical Sciences. [July 

9. Rarity of Consumption in Marshy Countries. — M. Nepple, of Lyons, in an 
interesting comniunication to the French Academy of Medicine, has brought for- 
ward evidence to prove that phthisis is a very rare disease in marshy countries. 
He states that, from the year 1818 to 1829, during which he practised in the 
marshy canton of Montluel, he was struck with the small number of consump- 
tive, scrofulous, and even goitrous individuals he met with. On investigating 
the subject more minutely, he found that the more marshy the district, and the 
greater the number of stagnant ponds and morasses, the more rarely did he 
observe any traces of these diseases in the farmers and labourers of the district. 

To obtain more numerous facts, he wrote to several of his medical brethren 
in the surrounding cantons, to ascertain whether the same fact had been observed 
by them. M. Duteche, physician in the canton of Chalamont — a canton mucb 
fuller of ponds and marshes than that of Montluel — wrote in answer, that he 
had never seen phthisical or scrofulous individuals in the communes of Mar- 
jieux, Versailleux, Lachapelle, or Saint Nizier-le-Desert, all situate in the Pays 
de Dombes, where the stagnant marshes are very numerous, and the population 
very unhealthy. He added, that so convinced was he of the advantages phthi- 
sical patients would derive from a residence in such localities, that he purposed 
to establish a maison de sante in an ancient chateau which had been abandoned 
by its proprietor on account of its general unheallhiness. 

M. Pacoud, of Bourg, during the course of a practice of forty-five years, had 
not met with a single instance of phthisis during all that time. The hospital 
of Bourg, which receives its patients from all the surrounding marshy districts, 
does not contain in its records the history of even a single case of this disease. 
M. Pacoud adds, however, that children who are boarded away from home, and 
consequently leave those marshy districts in early life, are occasionally affected 
with consumption, but removal to the marshy district does not appear to remove 
the disease. Dr. Hudelet, of Bourg, bears witness to the satne fact of the infre- 
quency of phthisis in the marshy districts of Villars, Marlieux, Saint-Nizier ; 
he never saw a single case of that disease. 

Dr. Monfrin, physician to the Hospital Chatillon-les-Dombes, states that 
phthisis is very rare in the country of the Dombes; for three years that the 
Mayor of Chatillon and he kept registers of the deaths in the town, out of four 
hundred deaths, including those in ihe hospitals, only eight were from phthisis, 
and one of these was a stranger. The canton of Chatillon, it may be remarked, 
is not situated in the most marshy district of the Dombes. 

MM. Rater and Candy, of Lyons, who had formerly practised in the marshy 
plains of Forez, bear evidence to the rarity of phthisis in that locality. M. Candy, 
however, stated that it has become more frequent of late years since several of 
the marshes have been drained. 

M. Jolly concurs in the statement as to the rarity of phthisis in the marshy 
district of Arcachon. 

From all these authentic facts, M. Nepple concludes that it is impossible to 
doubt the fact of the rarity of tubercular diseases in marshy districts, whatever 
explanation may be given of its cause. — Bulletin de VAcad. Royale de Med., 
7 Nov. 1843. 

10. New Diagnostic signs in Febrile and other Diseases, which present a Ty- 
phoid character. — According to M. Ranque, the pathognomonic sign of a fever 
which is likely to prove serious, is a coating like molher-if-pearl, of the gums 
between the molar teeth. If, in addition, leeches have been applied to the 
ipciUent, ihe bites will assume ihe colour of indigo. This last symptom is quite 
characteristic, and, when observed, we may rest assured that however mild the 
symptoms may appear, they will, before long, assume a very serious appear- 
ance. But M. Ranque has gone further than this. He states, that when this 
pearly tint between the molar teeth disappears under the pressure of the finger, 
the typhoid symptoms will not be very severe. But if the exudation be thick, 
not disappearing under pressure, and occupying many of the interstices between 
the teeth, we may look for a severe and long-continued attack. As the disease 



1844,] Medical Pathology and TTierapeutics, 205 

advances, the colour of the appearances changes; it becomes black, and what 
are called sordes (fuliginositea) appear. The same remarks apply to the bites 
of leeches. The deeper the indigo colour, the more serious is the attack likely 
to prove. If these signs exist at the outset of an attack of pyrexia, they are, 
according to the author, infallible marks, either of a typhoid fever, or of inflam- 
mation, accompanied by symptoms of a typhoid character. — Journ.de Med. et de 
Chirurg. Pratiques, Jan. 1844. 

11. Softening of the Spinal Nervous Substance. — Inordinate Venery. — Case of 
General Paralysis. By Sir B. Brodie. — One of the most common causes of 
paraplegia, commencing in the lower limbs, is a morbid change of the minute 
structure of the spinal cord ; that is to say, softening or ramollissement. The 
change that occurs at other times in the brain takes place in the spinal cord 
after a concussion of the spine. A very common effect of concussion is to injure 
its minute structure, and then, to a greater Or less extent, it dissolves itself into 
a substance like cream. In this state of softening it first loses its natural con- 
sistency, but still retains the character of solid substance. By and by it becomes 
completely melted down to a substance like cream; the membranes can hardly 
be lifted out, and when placed in water, the spinal cord floats, and the mem- 
branes remain by themselves. What produces this softening I cannot say. 
Some have said that it is inflammation, but certainly there are no marks of 
inflammation; there is no unusual vascularity preceding or accompanying the 
softening; there are no vessels loaded with blood, and, indeed, the parts are 
rather less vascular than natural. All that can be said is, that there is some 
peculiar change of structure, the proximate cause of which we cannot explain, 
nor very often the remote cause. A young lady had this state of the spinal cord, 
and ultimately died from it. She was a healthy young woman in other respects, 
and there was nothing to explain it. There is one very common cause of it — 
not in young women but in men — men who rank among what is called the better 
classes, which, I suppose, means only that they are richer than others; at any 
rate, they are not better in the point I am going to mention. There is a class of 
people, in London especially, who have no employment, who have large for- 
tunes, and who spend half their time in intriguing with women; and in many 
instances you may trace the disease of the spinal cord to over-indulgence in 
sexual intercourse. Though we know more of the appearances after death than 
did the ancients, yet they very well described paralysis arising from this cause 
when they spoke of it as tabes dorsalis. 

It has been said that paraplegia — paralysis of the lower limbs generally — 
depends on disease of the brain and not of the spinal marrow. This was main- 
tained by Dr. Baillie, and published in a paper of his in the Transactions of the 
College of Physicians; but he gives no facts on which the opinion is grounded. 
It seems to have been a notion taken up by him without any facts to justify it. 
However, there is reason to believe that, under certain circumstances, disease of 
the brain may produce paralysis in the lower limbs before it produces it in the 
upper. I examined the body of a man who was paraplegic, and I found water 
in the ventricles of the brain, but no disease connected with the spinal marrow. 
That you may have disease, however, in the brain and in the spinal marrow, 
combined in the same individual, there can be no doubt. Some of those young 
men who, from foolish habits, become paraplegic in the lower limhs, have also 
cerebral symptoms. There may be softening of the lower half of the spinal 
marrow, and of a good part of the brain. I think that if there is an entire 
absence of cerebral symptoms, you have a right to conclude that the disease 
does not exist in the brain, but is confined to the parts below; if, however, the 
patient says he has double vision, if you find one pupil dilated, and not the 
other, and there be pain in the head and giddiness, you have a right to conclude 
that there is disease in the brain; but still, if there were absolute paralysis, I 
should conclude that there was disease in the spine also. 

The case which I am about to mention is a very remarkable one. About 
nine years ago I was sent for into Lincolnshire to see a gentleman who was 
JNo. XV.—JuLY, 1844. 18 



206 Progress of the Medical Sciences, [July 

paralytic in the lower limbs. The symptoms of paralysis had exhibited them- 
selves eight years before, and at the same time there was pain referred to the 
epigastrium. The disease had now extended upwards, the arms were begin- 
ging to be affected, and there was also dilatation of the pupil of one eye; but at 
the commencement it was a case of regular paraplegia. Neither my advice nor 
that of any one else did any good, and the disease was left alone. Ten years 
afterwards his wife was very ill, and he was brought with her to London. She 
came for medical advice; but his case being considered hopeless he did not 
consult any one. He was now completely paralytic in his limbs and arms, he 
could scarcely speak, and he could only just swallow. He lay as though the 
head were alive and nothing else. His wife died, and he soon followed. I 
obtained leave to examine the body. Mr. Tatum and another friend accompa- 
nied me. We all three made a very careful examination. What we might 
have found if the spinal cord and brain had been macerated in alcohol, and if we 
had traced the fibres and examined them with a microscope, I cannot pretend to 
say; but, with such an examination as we could make in a private house in the 
course of a couple of hours devoted to it, we could not detect any morbid appear- 
ances at all. The spinal cord seemed rather smaller in size than usual, there 
was some little effusion between the pia mater and the arachnoid, and at the 
upper part of the spinal cord there was manifestly a blush. The patient had 
felt for a considerable time pain in the epigastrium, and I thought that might 
indicate some disease in the plexus there. We took it home with us ; Mr. Tatum 
dissected it with the greatest care, but nothing could be discovered. Do not, 
however, suppose that I believe this to be a mere functional disease, because we 
see nothing after death. The minute organization of the brain and spinal mar- 
row is not visible to the naked eye, and even with the microscope you can only 
trace it a little way. I doubt not that there was some defect in the minute 
organization of the body, some change of structure not perceptible to us. I can- 
not suppose that such a train of symptoms could occur from mere functional 
disease. — Lond. §r Edin. Monthly Journ. Med. Sci.^ April, 1844. 

12. Neuralgia cured by Inoculation of Salts of Morphia. — Dr. Jaques, of Ant- 
werp, being called into a young girl who had a very obstinate supra-orbital 
neuralgia, had in vain employed antispasmodics, the sulphate of quinine, and 
the salts of morphia by the endermic method: he conceived the happy idea of 
introducing som« sulphate of morphia by inoculation under the skin. For this 
purpose, having dissolved two or three centigrammes of the sulphate of morphia 
in a small quantity of water on a bit of glass, he took up this solution by means 
of a vaccinating lancet, and made about forty punctures over the seat of pain ; 
a marked relief ensued. The operation was repeated for some days, and the 
patient, who had been for a long time ill, was completely cured. The same 
plan of treatment has been applied in the treatment of sciatica ; the inoculations 
have been made the whole length of the sciatic nerve, and the patients, on 
whom all other kinds of treatment had produced no effect, have been completely 
cured. Each puncture is immediately followed by a white elevation of the skin, 
which disappears on the next day. Poultices are useful to subdue the irritation 
arising from the punctures. 

This is a certain and speedy mode of administering energetic medicines; and 
it is probable that it may usefully be had recourse to in many other circum- 
stances. — Lond. and Ed. Month. Journ. Med. Sci.y May 1844, from Bouchardat^s 
Jinnuaire de Therap. for 1844. 

13. Scirrhus of the Pancreas. — Dr. Battersby read before the Surgical 
Society of Ireland, March 30, a remarkable case of scirrhus of the pancreas — 
a disease of rare occurrence. 

The subject of the case was a woman between 55 and 60 years of age, who 
had been remarkable for her embonpoint, and had always enjoyed good health 
until two years previously, when she became subject to severe pains in the 
back, which afTected also the shoulders and arms, and were supposed to be 



1844.] Medical Pathology and Therapeutics, 207 

rheumatic. After the lapse of a year, there was discovered in the epigastric 
region a deep-seated pulsating tumour, ahout the size and shape of an orange, 
having a regular diastolic enlargement synchronous u'ith the pulse, and a well 
marked bruit de soufflet. Her disease was in consequence considered to be 
aneurism of the aorta. She also suffered from fluid eructations, and an obscure 
deep-seated pain. Dr. Battersby found her extremely emaciated. There was a 
marked fulness in the epigastric region, in which was to be felt a deep-seated, 
solid, and fixed induration, having a flattened surface and defined outline infe- 
riorly. It was without pulsation, but a bruit de soufflet was audible on the 
application of the stethoscope over it in the course of the aorta. She suffered 
much from constipation, from symptoms of contraction of the colon, and from 
temporary dysphagia. There were occasional eructations of a clear watery 
fluid, and her mouth seemed always full of saliva. The tongue was pale and 
clean. Before death the limbs became highly anasarcous, and there was some 
fluid in the abdomen. On examination after death, the colon and cardiac orifice 
of the stomach were found narrowed. 'J'he pancreas was universally hard and 
enlarged, and had lost every trace of its natural structure. Near the centre of 
this gland, and at its lower edge, existed a thin, translucent, horny cyst, which 
was slightly prominent, about the size of a walnut, and lay directly over the 
aorta. Its base was surrounded by a hard cartilaginous scirrhous formation, 
which, in part, projected into it. The rest of the gland was composed of a 
less solid, but unyielding heavy substance, apparently made of dense closely 
interwoven membranous bands. The lining membrane of the aorta was dis- 
eased, and in some points was eroded. The error committed of mistaking the 
tumour of the pancreas for aneurism of the aorta was due, no doubt, to the 
early development of the cyst, which, probably in the progress of the disease, 
had its fluid contents lessened by the encroachment of the scirrhus, while, the 
close union of the latter to the spine having removed the impulse of the aorta, 
towards the conclusion no other symptom remained but the bruit de soufflet 
which was not of itself likely to mislead. Ptyalism, as remarked by Dr. Bat- 
tersby in this case, has not been observed, in connection with diseases of the 
pancreas, by any writer in our language, so far as he is aware, although it has 
been frequently noticed by our continental brethren. Dr. B. thinks that this 
symptom may serve as a guide towards the diagnosis of pancreatic diseases of 
which the other symptoms are in general very obscure and ambiguous, and in 
this he is confirmed by the facts of a case communicated recently to him by Mr. 
Robert Macdonnell, in which the cleanness and great moisture of the tongue 
and mouth attracted the attention of three German physicians in attendance on 
Dr. Graves' Clinique, who, from this circumstance, principally, were led to 
pronounce the patient to labour under scirrhus of the pancreas, and although the 
post-mortem examination showed that the disease was not confined to the pan- 
creas, yet that gland was sufficiently engaged to confirm the accuracy of their 
opinion, founded on the extreme moisture and the pale and macerated appear- 
ance of the tongue. — Dublin Med. Fress, April 17, 1844. 

14. Scirrhous Tumour in Spinal Marrow. By M. Bouillaud. — A man, about 
24 years of age, was admitted, on the 10th of June, into the hospital of La 
Charite. Since winter he had been complaining of flying rheumatic pains, 
which for the last two months had become more severe, had been confined to 
the neck and shoulders, and obliged him to keep his bed. On a careful exami- 
nation, the spinous process of the lowest cervical vertebra was found projecting 
more than usual, and pressure on it was painful. There was no loss of move- 
ment or of sensation in any part of the body. Defecation and micturition were 
free, the appetite was good, tongue clean, pulse 92, and heat normal. He was 
bled, blistered, and put on low diet. On the 19lh sleeplessness, with severe 
headache, came on; his pulse fell to 52, was irregular and intermittent. On 
the 22d his countenance had a semi-idiotic look, he heard with difficulty, had 
frontal headache and ringing in his ears. On the 25th, delirium and jactitation 
were observed; his face was pale, lips livid, respiration impeded, sighing, and 



208 Progress of the Medical Sciences, [July 

semi-stertorous, jaws closed; slight stiffness of the limbs was also remarked, 
and urine and faeees passed involuntarily. He died at ten of the morning. 

The spinal marrow was found surrounded by a copious effusion of limpid 
viscid serous fluid. On the lower portion of the cervical spinal marrow, a con- 
siderable swelling was remarked, which, when cut into, exhibited a tumour of 
about the size and shape of a large olive. This tumour was unconnected with 
the surrounding marrow, was on its posterior surface, and compressed it into 
two flat ribands, which were softened and injected. The tumour itself pre- 
sented, when cut into, all the characters of the true scirrhous degeneration. At 
all other points the spinal marrow was healthy. Nothing remarkable was 
noticed in the brain ; when cut into, it presented few more bloody points than 
usual. A tubercular mass was found on the upper side of the left lung. The 
other organs were healthy. — Ed. Med. and Surg. Journ.^ April 1844, from UEx' 
perience, Oct. 19, 1843. 

15. Elephantiasis cured hy Guaiac and Iodine. By M. Cazenave. — A woman 
in 1833, remarked a fulness in her right leg, which, without pain, gradually 
increased, so that she could not pull her slocking over it. It extended over the 
whole limb, and gradually increased in size, till the articulations of the hip and 
knee-joints could scarcely be seen, and the limb resembled a solid hard fleshy 
column. When it was in this enormously swollen state, she had two successive 
attacks of erysipelas in it, eight years after the limb began to enlarge. In 1841 
she came under M. Cazenave's care. The general form of the limb justified 
the name elephant's foot. All the usual -depressions and projections seen on 
the healthy limb had disappeared, under the enormous hypertrophy of the skin 
and cellular tissue. Thigh and leg were confounded in one sliapeless fleshy 
column. Two grooves, formed by a thick overhanging fold of skin, alone 
marked the situaiions of the thigh and knee-joints. The condyles of the femur 
and the patella could not be distinguished. The heel and sole of the foot were 
the only places not involved in the disease. The dorsum of the foot was enor- 
mously swollen, and overhung the sole. The skin was of a dead-white colour, 
but sound. No induration of glands or blood-vessels could be detected. The 
whole tumour had a solid resistant feel, giving a sensation as if pressure were 
made on a thick ball of India rubber. There was no pain, but the sensibility 
was notably deficient. 

She was ordered a strong decoction of guaiac and mezereon; the leg was care- 
fully bandaged from the toes, and every other day the bandages were removed, and 
vapour douches applied to the surface, and an ointment of hydriodate of potash 
rubbed on. She was put on generous diet and wine, and kept in bed. This 
treatment was continued for a little more than three months, by which time the 
leg was reduced to its former dimensions, being then equal in point of size to 
the sound one, with the exception of a part on the dorsum of the foot. 

M. Cazenave states, that he has met with several other cases, which have 
been all more or less benefited, and some even cured by this plan of treatment. 
—Ibid, from Ihid., Sept. 28, 1843. 

16. Contraction of the foramen lacerum posterius, in maniacs and suicides. — Dr. 
Kasloff, Prof, of Anat. in the University of Kiew, has for several years direct- 
ed his attention to the state of the great vessels of the brain in cases of insa- 
nity, and finds himself forced to the conclusion, that insanity in all its forms 
is most intimately connected with derangement of the circulation within the 
cranium. In the course of the year 1841, he had particular occasion to remark, 
that the foramen lacerum posterius was very commonly contracted in the skulls 
of those who had died insane, or who had committed suicide. The contraction 
generally occurred on one side only, rarely on both. In many cases he found 
the foramen, where it transmits the internal jugular vein, reduced to a mere nar- 
row slit, which with difficulty admitted a common probe. The furrow for the 
lateral sinus, which led to this contracted foramen lacerum, was neither so broad 
nor so deep as in ordinary skulls, and the thimble-like cavity was almost level 



1844,] Medical Pathology and Therapeutics. 209 

^ith the base of the cranium. The jugular vein that occupied it could not have 
had half, frequently not one-third, and occasionally not one-fourth of its usual 
diameter. The canalis carolicus of the corresponding side did not appear to 
have undergone any similar contraction of its diameter. Along with the con- 
traction of the foramen lacerum posterius, however, a conspicuous enlargement 
of those foramina which transmit veins from the interior to the exterior of the 
skull was very regularly observed : the foramen mastoideum, and foramen parie- 
tale of the corresponding side, for example, were found of two Paris lines in 
diameter, and supernumerary foramina presented themselves in situations where 
none are commonly seen. 

In every skull of a maniac or suicide in the anatomical collection at Kiew, 
Professor KaslofF observed the contraction of the foramen lacerum posterius in 
greater or less degree upon one or both sides; in seventeen of the twenty-one 
skulls belonging to the above category, the peculiarity was remarkably dis- 
played. On comparing the foramina lacera of the two sides, he found that where 
the one on the healthy side was four and a half Parisian lines in diameter, the 
contracted opening measured but two lines; where the healthy orifice mea- 
sured four and a quarter lines, the contracted one still measured only two lines; 
where the former measured three and a half, and two and a half lines, the latter 
measured but one, and one and a half line. 

In quoting these fncts. Professor KaslotT still admits that he has examined 
other skulls of maniacs where he observed nothing of the same kind. It is im- 
possible, however, not to regard the instances quoted as full of interest for the 
pathogeny of insanity. It seems quite certain that the afflux through the caro- 
tid and basilar arteries continuing unimpeded, if any, even a very slight hind- 
rance to the return of the blood by one of its principal channels be encountered, 
a stasis or accumulation within the vessels of the brain must of necessity ensue, 
and that this can be without influence upon that important organ, "the soul's 
frail dwelling-place," is admitted on all hands to be impossible. Now, here is 
a permanent obstacle to the due return of the blood fronj the brain, which, if it 
have not entirely escaped the notice of pathological anaiuinists, which it has not, 
appears never to have been viewed till now in its legitimate connection with and 
bearing upon functional derangement or organic disease of the brain. — Oppen- 
heim Zdtschnftfiir die gesammte Med., Jan. 1844. 

17. Antipsoric remedies. — Various new modes of curing the itch appear from 
time to time; and if it be true that the thing needful is the destruction of the 
itch insect, it is probable that some remedy may be brought into general use 
which may be equally certain, and less noisome, than the common sulphur oint- 
ment. M. Dornblueth recommends a combination of two parts of common soap 
and one of powdered white hellebore, made into a paste with boiling water. 
This must be daily rubbed into the parts affected, until the itching is succeeded 
by a burning sensation, after which daily ablutions and clean linen complete tlie 
cure. 

M. Aube declares that one friction with oil of turpentine effects a perfect cure; 
M. Cazenave says the same of a solution of iodine; and it is also stated that 
all essential oils, especially those of anise and peppermint, possess the same pro- 
perties. — Prov. Med. Juurn.j 24 Feb. 1844, from Bouc/iardat''s Annuaire de 
Therapeutique. 

18. Treatment of Scald Head. — A family named Mahon enjoy an hereditary 
celebrity for the cure of this troublesome malady; the method which they em- 
ploy consisting first of cutting the hair short, and softening the crusts with poul- 
tices or hog's lard, so as to remove them ; and then using every other day a 
depilatory ointment or powder; a fine comb being passed through the hair on 
the alternate days, so as to remove the hair which has been loosened by the de- 
pilatory. The powder which they employ has been found by analysis to be 
entirely composed of the ashes of vegetables, and the ointment is made of this 
powder with hog's lard. Now this treatment is not peculiar to the MM. Mahon, 

18* 



210 Progress of the Medical Sciences* ^uly 

for Sydenham used to recommend an ointment composed of equal parts of the 
oils of almonds and of bays, and of the ashes of wormwood, which was applied 
every morning, the head beinoc covered with a pig's bladder. We perfectly 
well recollect seeing some children a short time since, who had been treated by 
a quack with an ointment evidently composed of hog's lard and potass, the head 
being directed to be covered with a bladder. — Jhid. 

19. Nervous Tremor in Children. — Dr. P. Hennis Green relates in the Pro- 
vincial Medical Journal (Feb. 24, 1844,) three cases of nervous tremors, two 
occurring in children of 13, and the third in one of 11 years of age. 

Dr. G. considers it as one of those purely nervous disorders which often pass 
away as rapidly as they have appeared, and leave behind no trace of organic 
lesion to account for the variety or intensity of the symptoms. The chief 
characteristic of the disease is an equable and rapid oscillation of the limbs, in 
ihe line of flexion and extension. It bears some resemblance to chorea, 
from which it is distinguished by the peculiar oscillatory movement, very 
different from the irregular and involuntary motions^ observable in the latter 
named affection. The causes of nervous tremor in the adult are various; in the 
child the exciting causes seem to be the same, so far, at least, as we can infer 
from the cases on record. In the three examples which Dr. G. has related, the 
causes of the disease were grief, obstruction of the menstrual function, and the 
action of lead on the system. 

The absence of headache — of convulsive movements — of contraction of the 
limbs — and of other lesions of the motor and sensitive powers, will aid us in 
determining the true nature of the disease. Its treatment must in most cases 
depend on the nature of the affection with which the tremor is associated. The 
case in which the tremor was produced by lead, it was speedily removed by 
active purging. 

20. Large Doses of Nitrate of Potass. By Henry Bennet, — I have, during 
several 5'ears, seen the nitrate of potass extensively administered in very large 
doses., and have myself often thus prescribed it. It certainly is an irritant poison, 
and capable of giving rise, as such, to inflammation, and perforation of the sto- 
mach, if administered in large doses, but only when taken in the form of pow- 
der, or of a very concentrated solution. When largely diluted in a fluid, one or 
even two ounces may be taken in the twenty-four hours, not only without giving 
rise to any toxical symptoms, but with great benefit in certain stages of the 
economy. When the nitrate of potass is given in a small compass, and in a 
single dose, half an ounce will act as an irritant poison, and occasion acute 
inflammation of the mucous surfaces ; but if it is largely diluted a much greater 
quantity may prove innocuous, even if given in one dose, and is sure to prove so 
if administered in divided doses during the twenty-four hours. 

It is principally in acute rheumatism that large doses of the nitrate of potass 
have been given. From some researches made by one of my friends and late 
colleagues, M. Aran {Journ. des Connais. Medico- Chirur., 1841), it would appear 
that the nitrate of potass was used in large doses in the treatment of rheumatism 
during the last century by several English physicians, whose names I am unable 
to mention, not having M. Aran's paper by me. I believe, that M. Gendrin, 
the physician to the Hopital de la Pitie, is, of all modern physicians, the one 
who has paid the greatest attention to the therapeutic properties of large doses 
of the nitrate of potass in rheumatism. The number of cases which I have seen 
thus treated must, therefore, be great when we consider that more than two 
thousand patients sojourn in M. Gendrin's wards each year. Indeed, although 
1 have kept no statistical record, I should say that I have seen treated, or treated 
myself, at La Pitie, in this manner at least seventy or eighty persons labouring 
under acute rheumatism. 

With women we generally commenced with six drachms, rapidly increasing 
the quantity to eight, ten, or twelve. With men we generally began at once 
with an ounce, gradually increasing the dose to ten, twelve, fourteen, or sixteen 



1844.] Medical Pathology and Therapeutics. 211 

drachms. In the very great proportion of cases, however, M. Gendrin did not 
exceed the dose of twelve drachms, or approve of its being- exceeded. The salt 
was always administered dissolved in a large quantity of barley-water, sweet- 
ened with sugar, the proportion being about half an ounce to a pint and a half 
or two pints of fluid. This was the only beverage allowed to the patient, and 
taken by him as required. 

In this large number of cases I do not remember once seeing any toxical 
symptoms produced. The secretions of the skin and kidneys were generally 
increased, and sometimes those of the intestinal canal, but the principal action 
of the nitre seemed to be a sedative action, the pulse generally falling rapidly, 
both as regards frequency and strength. It is, no doubt, to this sedative contra- 
stimulant action that we must look to explain its undeniable efficacy in the 
treatment of acute rheumatism. 

I do not recollect having once seen any symptoms of renal irritation or inflam- 
mation produced by these large doses of nitrate of potass, and have never heard 
M. Gendrin, whose experience on the subject is necessarily very great, say that 
he had met with such a case. M. Martin-Solon, in the communication which 
he made last October to the Academy, on the treatment of acute rheumatism by 
large doses of nitre, does not mention having observed a single instance of renal 
affection to the thirty-three cases which he had treated by doses varying from 
one to two ounces. It cannot be said of these two physicians that renal affec- 
tions may have presented themselves without their having perceived it, as they 
are both accurate and conscientious observers, and have both paid particular 
attention to the pathology of the kidneys. M. Martin-Solon, indeed, is the 
author of one of the best French works on "albuminuria" which has yet 
appeared. 

I have myself not only administered an ounce or more of nitre in the four-and- 
twenty-hours, for many days consecutively, in acute rheumatism, but also in 
puerperal fever and in other inflammatory diseases, with, I think, marked benefit, 
and without ever observing any toxical symptom. — Lond, ^ Edin. Month. 
Journ. Med. Sci., 1844, from Lancet, Feb. 10, 1844. 

21. Sea-side Air as a Remedial Agent. By M. Guastalla, of Trieste. — The 
influence of a marine atmosphere in the treatment of various diseases has been 
recognized by physicians from the earliest times. But though dail}'' expe- 
riencing its advantages, they were ignorant of the true principles on which its 
salutary effects depended. And even since the discovery of the real constitu- 
tion of the atmosphere, various opinions have prevailed on this point. At first 
it was thought that the maritime air contained a larger proportion of oxygen 
than other air, that gas being disengaged in the course of the incessant decom- 
position of sea-water. Very soon, however, sea-salt was supposed to have 
been recognized as entering into the composition of sea-air, and works were 
written recommending voyages as a means of absorbing this substance by the 
lungs in various diseases thought likely to benefit by it. Strange to say, the 
early hypothesis of the greater oxygenation of sea-air has been revived in the 
present day, and a M. Assegond has maintained that in phthisis complicated 
with inflammation, the respiration of sea-air is injurious, owing to its being too 
stimulant from its higher degree of oxygenation. All the great authorities in 
chemistry, however, are decidedly opposed to the idea of any differences in the 
essential elements of the air of different districts ; and if the air of the country is 
more salubrious than that of towns, or that of marshes injurious, or that of the 
sea possessed of peculiar qualities, it appears to be owing to the circumstance 
of these varieties of air holding in suspension various foreign admixtures, for it 
is established that the relative proportions of the essential constituents of the 
atmosphere are everywhere the same. What, then, are the accidental admix- 
tures to which marine air owes its peculiar qualities? They are precisely those 
which are to be looked for from the nature of the case, — chloride of sodium and 
free muriatic acid. But this statement must be received with some degree of 
qualification. It has been proved by Berzelius that the air of the sea-side con- 
tains no acid or salt in combination with itself, and that the vapours rising into 



212 ' Progress of the Medical Sciences, [^^^Y 

it are purely aqueous. But durinsf the agitation of the sea, and particularly in 
high winds, and where the waves break violently upon the beach, a quantity of 
natural sea water is driven into the air, and may be conveyed to a greater or 
less distance according to circumstances. Thus, then, by whatever means they 
may have come there, sea air does contain in a state of suspension, certain pro- 
portions of sea salt, and of muriatic acid, which are inspired into the lungs, and 
there absorbed and conveyed into the blood. Now, the experiments of Albers 
and others on the respiration and absorption of these substances used medici- 
nally, prove that, though at first chlorinated respirations irritate the nose, the 
eyes, and the bronchial mucous membrane, yet, when absorbed, they very 
speedily exert a powerful antiphlogistic influence in chronic inflammations of 
the chest. In addition, sea-air contains very little carbonic acid, and so is 
purer than the air of towns. The free ventilation on the sea-side also prevents 
mephilic particles from accumulating as they often do in inland situations. The 
aqueous vapour constantly rising into the air from the sea, is another favourable 
circumstance rendering it fit for respiration in a number of diseases which we 
knovp^ are aggravated by breathing a drier atmosphere. From the same cause, 
the temperature of the sea-side is milder and less liable to sudden changes. 
These various circumstances explain the undoubted healthiness of sea-ports and 
islands. Practitioners in sea-port towns, so situated as to be fully exposed to 
the constant influence of sea-air, have been struck with the less degree of intens- 
ity which inflammatory affections present there, compared with what they do 
in inland situations. It is impossible, therefore to attach any weight to the 
statement of some authors, that sea-air is exciting, and injurious to phthisical 
patients. There is a period of the disease, that of suppuration, when no means 
will prolong life, but it is contrary to fact to suppose that the aid of the sea will 
hasten death. So convinced was Laennec of the importance of this remedy in 
chronic diseases of the chest, that he was induced to establish a kind of marine 
atmosphere in the wards of the Hopital de la Charite, by means of fresh njarine 
plants placed around the beds, and by making the patients take infusions of 
such plants. In such a case, however, the resources of art must of necessity be 
much inferior to those of nature, and the phthisical patients sent to hospitals are 
generally in far too advanced a stage of the malfidy to benefit much by these 
feeble imitations. From these and many other i^^nalogous observations which 
might be quoted, it results, tiiat in chronic inflammations of the chest, sea-air is 
of unquestionable benefit, in so far at least, that if it does not cure them all, it 
so far alleviates them, that they cease to be insupportable or incompatible with 
life. Farther, that instead of sending phthisical patients to the country to 
breathe the dry air of mountainous regions, tliey should be sent on sea-voyages 
or else to some well chosen, healthy, and favourably situated part of the sea- 
shore. — Ibid., from ^nnales de Therapeutique, Nov. 1843. 

22. Successful Treatment of Ovarian Dropsy without the Mdominal Section, — 
J. B. Brown, Esq., of London, relates in the Lancet, (May 4, 1844) four cases 
of, as he avers ovarian dropsy, cured by mercurials, diuretics, tonics, and tight 
bandaging, followed by tapping. 

The following are the principal points of treatment. 

" 1. Constitutional. — Mercurials administered internally, as alteratives, and 
externally by friction over the abdomen, and continued till the gums are slightly, 
yet decidedly affected, and this affection must be continued for some vt^eeks. I 
lay particular stress upon this point. At the same time diuretics must be given, 
and after the first week tonics should be combined with them. The food should 
consist of light animal diet, and should be unstiraulating, and the patient should 
take daily exercise in the air. 

"2. Local treatment. — The careful and constant application of tight flannel 
bandaging, so as to produce considerable pressure over the tumour. When it is 
proved that the abnormal action has been checked by a positive decrease of the 
tumour and a continuation of such decrease, or by a positive non-increase for 
some weeks, then the cyst should be tapped, and all- its fluid evacuated. 

"3. After-treatment. — Accurate padding and tight bandaging over the cyst 



1844.] Medical Pathology ayid Therapeutics. 213 

and body generally, for two or three weeks after tapping-, and the medicine and 
friction continued for at least six weeks. I would particularly wish to enforce 
the importance of the after-treatment, as on that depends, very much, the suc- 
cess or failure of the case. 

" It probably will, and may be argued," he adds, " by many, that these cases 
were not truly ovarian^ and thus endeavour to do away with any merit that 
would otherwise arise from the treatment; but I would draw attention to the 
facts, more particularly of the first case. I saw the young lady when the tumour 
was very small and deeply-seared in the iliac fossa. I watched its growth 
from time to time, and distinctly marked its circumscribed edges and felt the 
fluid when it was first rising out of the pelvis; and, moreover, my friend, Dr. 
Locock, whose experience in such cases is much greater than my own, at once 
pronounced it ovarian^ as well as all the other eminent men who saw the pa- 
tient. There can, therefore, I apprehend, be no doubt as to its character, nor 
do I think, when coupled with the succeeding cases, can there be any fear of its 
permanent cure." 

23. Pathological and histological researches on infiammaiion of the nervous centres, 
— We gave in our number for January last, p. 200, the general conclusions of Dr. 
J. H. Bennett, relative to inflammation of the nervous centres. We return 
again to this very valuable paper in order to give some further account of the 
results of the author's researches. 

On the nature of softenings of the nervous centres. — Much uncertainty exists in 
regard to the nature of the softenings so often met with. Dr. Bennett is of opin- 
ion that two kinds of cerebral and spinal softening exist, an inflammatory and 
a non-inflammato:y, which may always he distinguished from each other by 
means of the microscope. 

1. Character of inflammatory softening. — On examining under the microscope a 
portion of inflamed and softened nervous tissue, in addition to the normal, tubu- 
lar, and granular structure, there will be found, 1st, exudation granules coating 
the vessels, or floating loose, either isolated or in the form of masses ; 2dly, ex- 
udation corpuscles, with distinct cell-walls, and sometimes nucleated. The more 
pultaceous and difliuent the softening is, the more numerous are the granules and 
corpuscles. The nervous tubes and normal structures also then become more 
and more broken down. With regard to the nature of inflammatory softening, 
it appears to result from the active growth, development, and breaking-down of 
nucleated cells (exudation corpuscles) in the effused blood plasma. " It is no.t 
a mere maceration of the textures in serum. No doubt the serum performs an. 
essential part in the process, inasmuch as moisture is necessary for every species 
of growth. But we are of opinion that softening cannot be considered as de- 
pendent on inflammation without the existence of these bodies. So far from 
being connected, as some have supposed, with diminished nutrition, it is, in 
point of fact, an increased nutrition in the excess of blood plasma efl'used." 

2. Character of non-inflammatory softening. — Here the cylindrical and varicose 
tubes of the part are found more sot\ and easily separable from each other. They 
have more or less lost their natural firmness and consistence; are readily torn 
across; the varicosities are easily enlarged by pressure, and, when separated or 
broken off, assume a globular form. The tubes, also, are more or less broken 
down. No exudation granules, masses or corpuscles can be detected. 

The causes of non-inflammatory softening are four in number: 1st, mechani- 
cal violence in exposing the nervous centres ; 2d, a mechanical breaking up of 
the nervous tissue, by haemorrhagic extravasations, either in mass or infiltrated 
in small isolated points, constituting capillary apoplexy ; 3d, the mere imbibi- 
tion of effused serum, which loosens the connection between the nervous tubes, 
and diminishes the consistence of the nervous tissue ; 4th, the process of putre- 
faction. 

Some authors have endeavoured to distinguish inflammatory from non-inflam- 
matory softening, by the presence in the former of a zone of red vessels, or of 
purulent matter; this distinction, however, according to Dr. Bennett, is not a valid 



214 Progress of the Medical Sciences. [J"ly 

one, inasmuch as, according to his observations, the zone of red vessels is very 
rarely met with in inflammatory softening, and the infiltration of purulent matter 
has no real existence. The opinions which attribute softenincr to a lesion sui 
generis^ to diminution of nutrition, to gangrene, obstruction of arteries, &c., are 
also considered hypothetical in the highest degree. 

The symptoms which accompany the two forms of softening differ widely. In 
twenty-four observations, in which cerebral softening was discovered, exudation 
corpuscles existed in eighteen, in the other six no traces of these bodies could 
be found. In four, however, out of the eighteen cases of inflammatory soften- 
ing, there also existed in another part of the brain non-inflammatory softening. 
In the fourteen cases of simple inflammatory softening, well-marked symptoms 
invariably existed, such as loss of consciousness, preceded or followed by dul- 
ness of intellect, contraction and rigidity of the extremities, or paralysis. 

In three of the six cases of simple non-inflammatory softening, there was a 
large extravasation into one side of the brain, followed by sudden coma and 
hemiplegia. In the fourth and fifth cases there was sudden loss of conscious- 
ness, with convulsions, but no paralysis or contraction, and on dissection, capil- 
lary apoplexia, with central softening, was found. In the sixth case, with ex- 
tensive softening without effusion of blood, there was no disturbance of intellect, 
no contraction, no paralysis. Dr. Bennett considers that the softening arose 
from mechanical destruction of the tissue in the first three cases, and from post 
mortem action in the three last. 

Of the four cases in which both kinds of softening existed, in the first there 
was hemiplegia of the left side only. Softening was found in both corpora 
striata, but exudation corpuscles only in the right, the side opposite to the 
paralysis. In the second case there was impaired intelligence, loss of speech, 
disorganization of the eye, and convulsions before death ; there was no paralysis. 
Abscesses surrounded by inflammatory softening were found in the external 
portion of the left anterior and middle cerebral lobes, explaining the symptoms 
present; but there was also non-inflammatory softening of the central parts of 
the brain producing no symptoms whatever. In the third case there was para- 
lysis of both arms, contraction of the right, and tetanic spasms of the muscles 
of the mouth and neck. Inflammatory softening existed in the pons varolii, 
extending more to the left side; non-inflammatory softening of the right corpus 
striatum. In the fourth case there was headache, prominence of the eyeball, 
and coma, but no paralysis. A fungoid tumour was found at the base of the 
orbit, and an abscess in the anterior lobe of the brain, surrounded by inflamma- 
tory softening. There was also central yellow softening of tho left hemisphere 
producing no symptoms. 

Dr. Bennett considers that much of the obscurity which attaches to inflam- 
mation of the nervous centres arises from the fact that pathologists have hitherto 
confounded softening dependent on inflammation, with softening occasioned by 
post mortem changes or mechanical violence, and, consequently, have been asto- 
nished to discover extensive softening after death, no corresponding symptoms 
having existed during life; on the other hand, where well-marked symptoms 
have been present, nothing has been discovered after death, though inflammation 
actually existed, capable of demonstration by the microscope alone, which shows 
the presence of exudation corpuscles. 

Dr. Bennett next proceeds to make some remarks on the colour of softenings; 
the general relation between the symptoms and the seat of the lesion ; on con- 
traction of the limbs as a symptom of inflammatory softening ; on the curability 
of softening; and on the connection between softening and hasmorrhage. 

1. Colour of cerebral and spinal softenings. — Softening may be tinged red, yel- 
low, white, or gray, without, however, any essential difference as to structure. 
As a general rule, it would appear that the red may be considered as acute, the 
yellow subacute, and the white or gray chronic softening ; but this is by no means 
invariable. 

The red and yellow colour is evidently connected with the presence of blood 
or its colouring matter. Sometimes the yellow softening is contained within 



1844.] Medical Pathology and TTierapeutics, 215 

the reddened portion, and somewhat resembles a purulent collection. At others, 
it surrounds the extravasation of blood, as is most common. Some have supposed 
the purulent infiltration is the cause of yellow softening-, but such does not 
agree with the observations of Dr. Bennett, who has never met with a pus cor- 
puscle in softened brain or spinal marrow. 

In the fawn-coloured softenings, which are frequently observed independent 
of extravasated blood, the author has always found exudation corpuscles, and 
thinks it very probable that the fawn tint is attributable to the presence of these 
bodies, which are usually of a brownish or blackish colour. 

White softenings are generally non-inflammatory ; in some cases, however, 
they contain numerous exudation corpuscles, which are then colourless. 

2. General relation between the symptoms and the seat of the injiammatory soften- 
ing, — In ten cases examined by Dr. Bennett, lesions of the central parts of the 
brain on one side were discovered ; the symptoms during life consisted of con- 
traction or paralysis of the extremities on the side opposite to the disease. In 
six cases there were lesions of the central parts on both sides; symptoms during 
life, contraction or paralysis on both sides of the body. In four cases, lesions 
of the peripheral parts only existed ; thii group was characterized by the ab- 
sence of paralysis or contraction of the extremities, and by either delirium or 
coma. This analysis, it will be seen, is favourable to the hypothesis which 
ascribes motion and sensation to the central parts, intelligence to the surface. 

3. Contraction of the limbs in inflammatory softenings and in hsemorrhage.—' 
Some dispute has taken place as to the presence of more or less contraction or 
rigidity of the limbs in inflammatory softening, some authors contending that 
it is a highly characteristic symptom, others asserting that its presence, when it 
does occur, is altogether incidental. Dr. Bennett is of opinion that, in idiopathic 
inflammatory softening of the brain, contraction in one or more limbs is a com- 
mon symptom. In simple hsemorrhage into the brain, on the other hand, with- 
out the existence of any inflammation, contraction seldom, if ever, occurs. 

4. The curability of cerebral and spinal softenings. — Though numerous obser- 
vations have fully demonstrated the possibility of this occurrence, Dr. Bennett 
considers that the anatomical marks or appearances, by means of which patho- 
logists have endeavoured to demonstrate the fact, are very fallacious. "The 
slight indurations occasionally met with in the nervous substance are spoken 
of by some authors as cicatrices — a term, we think, wholly inapplicable to them. 
Durand-Fardel alludes to the softening resembling chalky milk as a proof of 
the passage of the lesion into a state of cure, and Dr. Sims speaks of the fawn- 
coloured cavities as evincing the same fact." In one case of hemiplegia of long 
standing, in which the chalky milk softening was found, the granules of the 
exudation corpuscles were seen to be large, equal in size, and very transparent, 
in fact presenting a very unusual appearance; it is not improbable, therefore, 
that the granules were undergoing absorption; and consequently, the opinion of 
Durand-Fardel may be correct. On the other hand, the appearances described 
by Dr. Sims were met with in one case, but here, on the application of the 
microscope, numerous exudation corpuscles and granules were met with, pre- 
cisely similar to those seen in parts undoubtedly aflfected with acute inflamma- 
tion. Intense rigidity of the opposite side of the body also existed, without 
any other lesion than this which could at ail account for it. Dr. Bennett's 
opinion, therefore, is, that the fawn-coloured spots described by Dr. Sims are no 
evidence of the cure of inflammatory softening. 

5. The connection between s(ftening and hsemorrhage. — It has long been a ques- 
tion, does the hasmorrhage precede and cavise the softening, or does the softening 
ever precede and induce the hsemorrhage'? In three cases related, hsemorrhage 
took place suddenly, producing hemiplegia, and death within a fevv hours ; sur- 
rounding the coagulum the cerebral structure was softened, but apparently 
only mechanically, and no exudation corpuscles were found. In two other 
cases, with the same symptoms, death took place respectively in seven days and 
five weeks. Here the surrounding cerebral structure was softened, and nume- 
rous exudation corpuscles were discovered. Thus it would appear necessary 



216 Progress of the Medical Sciences, \J^^Y 

for a certain time to elapse before the haemorrhage can produce the inflammation. 
On examining the mode of accession, also, there is no reason for supposing that 
softening preceded the haemorrhage. In seven out of eight cases the attack was 
sudden, and in the eighth, where headaclie had existed for some time, this was 
evidently congestive, and the softening contained no exudation corpuscles or 
granules. 

With regard to the character of the softening that frequently surrounds apo- 
plectic clots or sanguineous infiltration, Durand-Fardel asserts, that if the soft- 
ening extend beyond the limits of the infiltration, if redness surround it, and if 
enough blood be not infiltrated to have mechanically produced a diminution of 
consistence, then the affection is inflammatory. If, on the other hand, the 
softening is slight, its extent limited, if lliere be an adhesion of the meninges, 
and if the surrounding parts appear healthy, then the aflfection is simply san- 
guineous infiltration. With these distinctions, however, our author is not dis- 
posed to agree; two cases are brought forward, in one of which the appearances 
first mentioned were presented, whilst the second resembled what is described 
as simple infiltration. In neither case could any corpuscles or granules be dis- 
covered. 

At this point Dr. Bennett pauses, promising, however, to renew the inquiry 
at some future period. The subject is one of the highest interest, and the ob- 
servations of the author are deserving of the utmost attention. — Med. Chir. Rev* 
from Edin. Med. and Surg. Juur7i., Oct. 1843. 

24. Inoculation of Veiraria in Neuralgia, — M. Lafargue has, in many cases 
of Prosopalgia, had recourse to this endermic mode of treatment with singularly 
good effects. The plan he follows is nearly the same as that used for vaccina- 
tion : a number of punctures are made with the point of a lancet that has been 
charged with a saturated solution of the alkaloid. Each puncture becomes at 
once the seat of a sharp pain, which is usually compared by the patient to a con- 
tinual deep pricking with the point of a needle. This unpleasant sensation lasts 
from five to fifteen minutes, and then gradually subsides ; and with it, the red 
areola that has formed around the punctured spot. M, Lafargue recommends, 
in severe cases, that the inoculation be repeated morning and evening; and that 
as many as ten or twelve punctures should be at a time. He has used the same 
method of treatment with decided good effects, in several cases of partial para- 
lysis. — Ibid. 

25. Nux Vomica in Neuralgia. — M. Roclants, a Dutch physician, reports 
most favourably of the effects of this potent drug in severe cases of neuralgia of 
the face and other parts, and communicates at the same time the therapeutic re- 
sults obtained by many of his professional friends. Out of the twenty-nine 
severe cases, a perfect cure was effected in twenty-five, and decided relief was 
afforded in the other four. The dose, in which the powdered nux vomica was 
administered, was from three to ten grains, and upwards, in the course of the 
twenty-four hours. In all cases its effects should be narrowly watched, as un- 
pleasant consequences have occasionally resulted from incaution on the part of 
the physician. M. Roclants is inclined to regard the nux vomica as, on the 
whole, the most efficient and certain remedy against severe neuralgia; he has 
seen several cases, which had resisted the long administration of steel, bark, and 
all the other most approved means, yield to its use. 

M. Trousseau has recently been very strongly recommending the strychnos 
as a most valuable remedy in obstinate chorea. — Ibid. 

26. Belladonna in Dysmenorrhxa. — T>r. G. Bird has found belladonna, properly 
prepared, of the greatest eflScacy in that form of dysmenorrhcea which was 
unaccompanied by organic change, or attended by the discharge of shreds from 
the uterus, and in which the pain was referred to the lower part of the abdomen, 
immediately over the uterus. When the patient was of a leuco-phlegmatic 
habit, pale and chlorotic in appearance, he ordered five grains of extract of bel- 



1844.] Medical Pathology and Therapeutics, 217 

ladonna and twenty grains of sulphate of zinc, to be divided into twenty pills, 
and of these one was ordered to be given innmediately on the accession of pain, 
and repeated every two or three hours, until the pain ceased. When the patient 
was plethoric and of full habit, he substituted ten grains of ipecacuanha for the 
zinc, and the pills were given in the same manner. In the intervals of men- 
struation, purgatives were administered, with medicines tending to improve the 
general health. This treatment he had scarcely ever known fail. — Lancet^ March 
23, 1844. 

27. Nitrate of Potass in Spasmodic Jlsthma. — Dr. Frisi has tried this remedy 
in the manner advised in our No. for Jan. 1842, p. 262, in a case of spasmodic 
asthma, which had obstinately resisted all other treatment. The relief was 
instantaneous, and the remedy never failed to cut short the attack as often as it 
was repeated. — II Filiatre Sebizio. 

28. Continued Inflammatory Affections modified by Marsh Miasmata. — During 
the course of a discussion on the use of the sulphate of quinine in intermittent 
fevers, at the Medical Society of Gand, an interesting communication was made 
by M. GuiSLAiN, on the influence of marsh miasmata in the |)roduciion of cer- 
tain acute continued forms of disease, which necessitate the use of sulphate of 
quinine. The views of M. G. accord with those advocated by Dr. Boling, in 
an interesting article in the original department of this Number. 

We subjoin a brief analysis of the former memoir. 

" For more than fifteen years I have observed, every now and then, inflamma- 
matory diseases, which I have treated with miraculous efficacy by the sulphate of 
quinine; they have been specific inflammations, and not larvaceous or pernicious 
fevers, such as have been generally described. The inflammatory affections of 
internal organs which I have oflenest been obliged to treat by the sulphate of 
quinine, are more especially groups of cerebral symptoms, which it would be 
difficult to particularize by a special name. They who are satisfied with the 
usual denominations would call them cases of meningitis, arachnoiditis, ence- 
phalitis—cerebral fevers. These terms, however, never satisfied me; I always 
found more than the ordinary symptoms of these diseases in the cases to which 
I allude. 'J'hey presented the phenomena which is generally termed ataxic, and 
which manifests itself by something sudden and alarming in the progression of 
the disease. Moreover, although the symptoms of deep lesion of the cerebral 
functions were present, there was absence, as in adynamic fevers, of the true 
symptoms indicating inflammation of the meninges or of the cerebral substance, 
viz., the muscular contractions, followed by local or general paralysis. In 
every case which I have seen there was great pain felt in the region of the fore- 
head, of the temples, of the crown of the head, and, less frequently, of ttie occi- 
put. This cephalagia sometimes assumed the character of a rheumatic pain, 
passing from one region to another. The t'ever was continued, intense, and the 
general depression consequently great. Delirium appeared in some instances 
before the patient was obliged to take to his bed. 

"In cases of this kind I have given the sulphate of quinine with great and 
nearly instantaneous success, the cephalagia at once disaj>pearincr, then the deli- 
rium ; the cardiac pulsations becoming slower, the fever vanishing, and conva- 
lescence taking place in the course of a few days. 

*' I will now endeavour to enumerate the principal points by which I am 
guided in thus resorting to the use of quinine. 

" I take into consideration the locality in which the patient is living, its 
proximity to water, or to a marshy district; the time of the year (summer heat 
being favourable to the development of the diseases caused by marsh miasmata), 
and tlie medical constitution of the period. I recollect thai in the form of dis- 
ease of which I am speaking, the manifestation of the morbid phenomena is 
generally instantaneous; that from the first there is great adynamia, to which 
delirium soon succeeds. 1 must add that there is never any remission in the 
febrile symptoms, and that the urine is not red, as in inflammatory diseases, but 
No. XV.— -July, 1844. 19 



218 Progress of the Medical Sciences, [Ju^y 

pale, rather troubled, and deposits a mucous sediment, like the urine of patients 
to whom the sulphate of quinine has been administered in intermittent fevers. 
In these cases the skin often presents the same deadened earthly coloration 
which is observed in those who have long resided in marshy disiricis. This 
form of disease is not confined to cerebral affections; it may be observed in the 
thoracic and abdominal inflammations. In such cases antiphlog-islic remedies 
constantly fail to ameliorate the state of the patient; indeed, bleeding 1 have 
often seen to aggravate the cephalagia and all the other symptoms. This being 
the case, the want of success of tlie first antiphlogistic remedies resorted to may 
often be a valuable indication of the true nature of the disease." — Bulletin de la 
Soc. Med. de Gand. 

29. Alcoholic Lotion in Phthisis Pulmonalis. — Dr. Marshall Hall extols the 
efficacy of an alcoholic lotion constantly applied by means of six folds of linen 
over and across the upper lobes of the lungs, in checking the deposition and 
softening of tubercles in the lungs. 

" One part of pure alcohol is mixed with three parts of water. It is applied 
tepid at first, afterwards of the temperature of the atmosphere. It is applied, in 
small quantity at a time, every Jive minutes, so that the application may always 
consist of alcohol and water. (If applied in larger quantity and less frequently, 
the alcohol would evaporate, and water alone would be left, and this would be 
the source of a feeling of discomfort instead of the feeling of glow which the 
alcohol induces.) The application is easily made; a piece of soft linen, of the 
size of a very large sheet of letter-paper, being folded in the usual manner, is 
then folded twice more, in lines parallel with the first, so that the whole consists 
of six folds. These are stretched, applied across the upper part of the thorax 
just below the clavicles, and fastened to the shoulder-straps, or other part of the 
dress, which latter is to be arranged so as to be readily opened and closed. A 
sponge, the size of a walnut, is then filled with the lotion, and pressed upon the 
linen along its whole course, the dress being opened for this purpose and imme- 
diately closed. 

" This operation need not occupy five seconds. It should be repeated, as I 
have stated, every five minutes. The application of the lotion should be inces- 
sant during the day and all waking hours, the dress being light, or even 
entirely removed, so as to allow of free and rapid evaporation. It is suspended 
during the night. 

" It is by no means my wish to laud this remedy beyond its just value ; but I 
have no hesitation in asserting that it possesses a power in checking the progress 
of the deposition and softening of tubercle in the lungs, beyond any other which 
I have ever tried. And the number of patients who have recovered from inci- 
pient phthisis under its use, and who, after many years, are still living, and in 
apparent health, induces me to express myself in strong terms in regard to its 
extreme value. 

*' One patient, who consulted me fifteen years ago, had dulness on percussion, 
and pectoriloquy, and every other sign of incipient phthisis. He applied, and 
long wore, the alcoholic lotion, called it his ' breast-plate,' and is now a pro- 
fessor of College. 

"A lady, about thirty years of age, became affected with haemoptysis, and 
displayed the physical signs and the usual symptoms of phthisis. She was 
enjoined the alcoholic lotion. It is fourteen years since it was first applied, and 
it is continued, or renewed, if ever suspended, to this day. 

" I saw a youhg lady two years ago, one of a most consumptive family, 
affected with haemoptysis, and with every threatening sign and symptom of inci- 
pient phthisis. I prescribed the alcoholic lotion, and the cough and hosmoptysis 
were removed, and every fear dispelled. It had already been proposed that this 
young lady should take a voyage to Madeira. She did so, continuing the lotion, 
and returned in apparent good health." — Lancet^ April 20th, 1844. 



1844.] Medical Pathology and Therapeutics. 219 

30. Epidemic Fever hi ely prevalent in Scotland. — A variety of continued fever 
differing' from the ordinary typhus or typhoid forms, has been prevalent in the 
larger towns of Scotland for eighteen months past. We have already given an 
excellent notice of this fever (see preceding Number, p. 450,) but as the disease 
will probably reach this country, indeed we suspect it has already appeared, for 
the Roundout fever has many points of resemblance to it, we shall give some 
further details respecting it. 

Dr. CoRMACK, in an interesting volume on this fever, which he had an oppor- 
tunity of studying at Edinburgh, describes two forms of the disease, first, the 
moderately, and secondly, the highly congestive, the symptoms of which he 
gives as follow: 

" Ordinary., or Moderately Congestive Form of the Disease. — In ordinary cases, 
the countenance of the patient has a peculiar appearance, which we may 
designate bronzed., for want of a better term. Though no words can accurately 
convey what is thus attempted to be described, the appearance itself is very 
characteristic, and has never failed to arrest and interest the medical visitors to 
the hospital, to whom it has been pointed out. 

"The symptoms of invasion are in all cases remarkably similar, both as to 
their nature, and order of occurrence. 

*' Tlie patient is first seized with coldness, rigors, headache, pain in the back, 
and more or less prostration of strength; but the latter symptom, it must be re- 
marked, is often not at all urgent, many walking long distances from the country 
to the hospital, especially during the first days of the disease ; and a still greater 
number of the destitute town patients lounge about the streets after their seizure, 
and come into us on their legs. 

" After a period, varying from less than half an hour to several hours, the 
cold fit terminates, when the severity of the headache greatly increases, and a 
dry burning heat comes over the whole body, accompanied by much thirst and 
general uneasiness. 

"The hot stage is succeeded by a sweat, usually very profuse, continuing for 
a number of hours, and seldom attended or followed by any relief to the headache 
or other pains. 

"Sometimes, though rarely, there is no sweating for two or three days after 
the seizure. Occasionally, also, there is no well-marked hot stage between the 
cold and the sweating fits; and in at least a few cases, the sweat breaks out on 
the face and upper part of the body, whilst the patient is yet in his initiatory 
rigors. 

"It is proper to remark, that during the whole course of the disorder, the 
perspiration has a characteristic disagreeable smell, and is decidedly acid, as is 
proved by its reddening litmus paper, and that sometimes with intensity. 

" During the three stages of the initiatory paroxysm, the pulse is rapid, being 
sometimes as high as 150, seldom below 90, and commonly ranging between 90 
and 120. During the rigors, in several cases, I have found it very wiry and tre- 
mulous; in the hot stage it is often hard, and not very easily compressed ; at the 
sweating period, it becomes fuller and softer, and does not exhibit that defi- 
ciency in strength, shown after, and during tiie perspirations of a more advanced 
period of the fever. 

" For the first forty-eight hours, the tongue commonly continues moist, exhi- 
biting at the same time a white or brownish yellow fur, excepting at the point, 
where there is usually a clear space, extending over a space, often (as in typhus 
abdominalis) shaped liked a triangle, the extremity of the tongue forming the 
base. Afterwards, the tongue becomes dry, and longitudinally streaked on the 
centre with brown, in which state it continues till the approach or arrival of 
the crisis, at from the third to the ninth, but in the majority of cases, on the 
fifth day. 

" During the first four days, some of the patients have occasional short rigors; 
but most commonly, they are in a state of dry ardent fever, with occasional 
sweatings. These sweatings occur, or at all events, commence in most cases, 
between two and nine, a. m.; but to this rule, there are many exceptions. In a 



220 Progress of the Medical Sciences, [J'^ly 

considerable proportion, even of the ordinary and mild cases, nausea and vomit- 
ing' usher in and attend the sufferings of the first days. Pain at the scrobiculus 
cordis generally accompanies these symptoms; not unfrequenily, it is present 
without them. A symptom which uniformly occurs during the first four days, 
is severe muscular and articular pain. General uneasiness, or pain in the abdo- 
men, (but particularly above the pubes, and over the liver and spleen, when 
pressure is made on these regions,) are very commonly, but by no means uni- 
formly met with. 

" So long as the patients suffer much from the symptoms now described, they 
sleep badly, and frequently not at all, unless opiates are administered. The 
severe pains in the joints and muscles are often sufficient to account for the bad 
nights complained of; but even with those who do not suffer much from this 
cause, sleeplessness is a distressing symptom up to the crisis. 

"A remission on the third day is very common. It occurred in all the cases 
which I have had an opportunity of attentively observing from the invasion 
onwards. 

" On or about the fifth day, there is an evident manifestation of the violence 
of the disorder being expended ; and this change for the better is often very 
sudden and complete. One day, we hear the patient moaning and groaning in 
pain; and on the next, he is at ease and cheerful, his only complaints being of 
hunger and weakness. This state is generally ushered in by a copious sweat; 
or by epistaxis or diarrhoea. The sweating was by far the most common critical 
evacuation till the beginning of October, when diarrhoea and dysentery, formerly 
rare occurrences, became common ; and at the present time (October 30) they 
are as usual as sweating. After this change, the pulse, tongue, and skin are 
quite natural; and the facial bronzing often becomes much less striking. For 
several days, or till about the fourteenth or fifteenth day of the disease, there is 
a period of intermission, during which a great deal of lost strength is regained, 
and a steady improvement goes on in all respects. 

" On, or about the fourteenth or fifteenth day from the beginning of the dis- 
ease, the patient relapses; or, in other words, has a paroxysm of fever, similar 
to that which began his first attack; The relapse takes place late or early, just 
according to the date of the first convalescence, as will be clearly seen from all 
the cases to be detailed. It sometimes happens, that the onset and progress of 
the second attack are attended by severer, and at other times, by milder symptoms 
than those of the first. In the relapse, the abortions most commonly take 
place. In it also, the muscular and articular pains are very often most severe. 
Cases, which in the first attack were strictly mild and ordinary, have in the 
second, become signalized by jaundice, delirium, diarrhoea, dysentery, and other 
grave symptoms. Such occurrences are, however, not common. 

"A large number of patients have a second and generally mild relapse, on or 
about the 21st day. As these relapses take place often after dismissal from the 
hospital, it was some time before I discovered the frequency of third attacks. 

" In those who are young and of good constitution, the convalescence is rapid 
and complete. In the old and debilitated, it is otherwise ; but I have never seen 
any one, old or young, die of the ordinary form of the fever." — pp. 3-6. 

" Highly Congestive farm of the Disease. — Although many of the cases issuing 
in death, or characterized by extreme severity, present symptoms very different 
from those hitherto detailed, there can be no doubt, that the disease is essentially 
the same, the difference being one only of degree, as will be more specially 
unfolded hereafter. Both forms are undoubtedly the result of the same morbid 
poison. 

"One of the most common symptoms in the highly congestive form of the 
disease, is yellowness of the conjunctivas, and of the whole surface of the body. 
It generally appears between the third and seventh day, and is always most 
intense on the face, neck, chest, abdomen, and thighs. The hue of the neck 
and chest is the most vivid ; then comes, of equal, or nearly equal brightness, 
the abdomen ; then, somewhat fainter, the thighs ; then, considerably paler still, ^ 
the legs, arms, and fore-arms; the hands and feet get their colour later, always 



1844,] Medical Pathology and Therapeutics, 221 

to a much lesss extent, and sometimes not at all. The yellowness occasionally 
appears during the relapse, and not in the first attack. I have seen it present in 
both. 

" Associated with the yellowness, there are generally depression, less or 
more delirium, dusky, and often porter-coloured urine, black melaena-like stools, 
and haemorrhapres from some of the mucous membranes. In the worst of the 
cases, black cotfee-ground like matter is ejected from the stomach, and passed 
per anum. 

"In some cases, the black vomit occurs without the yellowness; and, on the 
other hand, at the autopsy of yellow patients who have had no black vomit, 
this matter has been found in the stomach, and other parts of the alimentary 
canal. 

" Enlarged liver and spleen, and tender and tympanitic abdomen are less 
constant, but still very usual symptoms in cases characterized by yellowness or 
extreme congestion. Difficult micturition has been complained of by several of 
my yellow and purple patients. 

" A deep persistent purple colour of the face, appearing before, or immediately 
after the invasion of the disease, is a certain prognostic of danger, and is seldom 
absent in those destined to be yellow. Since I first made this observation, it 
has received, among others, two notable verifications in the cases of my assist- 
ant. Dr. Heude, and Mary Wallace, one of the nurses. Dr. Heude I pointed out 
to my other assistant, Mr. Reid, as deeply purple at noon, when we were 
engaged with ihe visit: — at 3 p. m. he was in the iniiial paroxysm of the fever. 
Mr. Reid and I remarked Mary Wallace becoming first bronzed, and at last 
purple, before she was laid up, and in consequence advised her to take the chlo- 
rinated solution, which she did not do. Both became yellow, and both narrowly 
escaped with their lives. 

" With the exception of the purple countenance, the symptoms which usher 
in the congestive form of the disease, differ little from those attending the dis- 
order in its milder degree. As has already been remarked, there is some consi- 
derable difference in the cases as to the time at which the yellowness appears. 

" Generally, in the severe cases, there is merely a remission about the seventh 
day, but no intermission ; and even in those who died a (ew days later, a slight 
amendment was noticed about the usually critical period." — pp. 23, 24. 

'-'' Pathology of the disease. — The present epidemic possesses positive and ne- 
gative characters, strikingly distinguishing it from the fever which generally pre- 
vails in Edinburgh, viz. — 

" 1. The sudden and violent invasion of the disease. — 2. Bronzing, leadening, 
or purpling of the countenance before and after seizure. — 3. The almost uniform 
occurrence of one or more relapses. — 4. The unusual number of cases with yellow 
skin, black vomit, and haemorrhage. — 5. The short duration of the pyrcxiul state, 

and its mode of termination. — 6. The severe muscular and articular pain 7. 

T^he rosy, elliptical eruption resembling measles is absent in almost every case in 
ihe present epidemic. 

*' Whilst these are the principal characters which distinguish the two epide- 
mics, they also exhibit other marked differences ; for instance, in that which 
now prevails. 

" 8. Severe vomiting is much more common ; as are likewise gastric, gasiro- 
hepatic, gastro-splenic, and gastro-enteric symptoms.''^ — p. 84. 

Dr. Cormack fully illustrates these eight distinctive characters. We have 
only room to quote what is said under the two last heads. 

" The rosy elliptical eruption resembling measles is absent in almost every case 
in the present epidemic. — Certainly, one of the most remarkable distinctions be- 
tween the symptoms of the epidemic which now prevails, and that which has 
been common in Edinburgh for a number of years past, is the absence, with some 
rare exceptions, of the rosy, elliptical, and elevated spots resembling measles, 
which disappear on pressure, and return when the pressure is removed. 

" While ihe almost universal absence of the typhoid eruption presents an 
obvious ditference between the phenomena of the ordinary and present epide- 

19* 



222 Progress of the Medical Sciences, [Juty 

mics, yet its occasional presence sng-gests to us the important inquiry, whether 
the two fevers, though apparently so different, are not the results of modifica- 
tions of the same morbid poison? 

"On this subject Dr. Alison remarks: ' It is a curious and interesting ques- 
tion, whether this kind of fever has proceeded from the same poison as the 
usual typhoid fever of Edinburgh, or is truly a separate disease? It is quite cer- 
tain, that the one has succeeded the other, within narrow limits, both of time 
and space, in different parts of the town ; and I have seen two instances, in 
which strictly typhoid cases, with the characteristic eruption, have been brought 
in from the same rooms, in which a succession of the milder cases have occurred 
at the same time. But, on the other hand, 1 am aware of several cases, care- 
fully investigated by my friend and colleague. Dr. Henderson, in which a suc- 
cession of protracted typhoid cases has been traced to one room, while all the 
cases in the neighbourhood have been of the mild and short fever. And one man 
under my care, after passing through a protracted typhus, with the characteristic 
eruption, and threatening of ulceration of the bowels, relapsed, with the symp- 
toms of the usual epidemic, of which cases were lying beside him, and had the 
usual crisis, and second relapse, — so that he might be said to have gone through 
both diseases in their present form, before leaving the ward.' 

" We find the ordinary eruptive typhus driven from the field ; — the present 
form of fever gradually springing up as the other decreased. I am aware, that 
it has been alleged, in conversation, by some physicians, that the few cases 
which have presented the rose-red fever eruption did not relapse, — were of the 
continued type, — and, in fact, were cages of a diff'erent disease. To this opinion, 
I was also at first strongly inclined, more especially, as it was currently alleged, 
that these cases could be traced \o foci of contagion, where the same form of 
the disease prevailed. This opinion, however, is not tenable. It may be true 
that the cases of what are termed ' true typhus,' come pretty generally from 
the same houses; but then, do they not come also from the same families? 
May it not be a peculiarity of constitution in these individuals, which determines 
this particular manifestation of the morbid poison ? Though the constitution 
of an epidemic gives to it a character, yet idiosyncrasy causes families and indi- 
viduals to be affected differently from the generality of persons. Who will 
maintain that the scarlatina poison does not produce mild cases, without sore 
throat and eruption, as well as those with one or both of these characters ? 

" Now, no person who saw the rosy spots in the case of Mary Wallace, on their 
first eruption^ could say, that it v^-as not the true measly typhus eruption ; and 
yet, the bronzing, purpling, and jaundice, along with the urgent vomiting, 
rheumatic pains, and the relapse at the usual period, proclaimed unequivocally, 
that she was afflicted with the prevailing epidemic ; or rather, perhaps, a sort 
of bastard between the two forms of fever. She took the fever in the hospital, 
where, at the time of her seizure, there was not a single case that either had, or 
had had typhus eruption. Facts are wanting to enable us to speculate with 
advantage upon the question, as to whether all of those occasional cases with 
eruption proceed from the same poison as those without it; but this, at all 
events, can be stated, that there is such a thing as perso7is being occasionally 
affected with the measly eruption^ in addition to the usual symptoms of the pre- 
sent fever ; such persons, moreover, apparently getting the disease from a con- 
tagious poison evolved from, or generated by persons congregated together, af- 
fected only with the prevailing form of the fever. 

" When I commenced the observation and study of the present fever, and 
indeed, for a considerable time afterward, I regarded it as essentially and totally 
different from typhus; but recent circumstances, and more matured weighing 
of evidence, have greatly modified this opinion. In the case of Mary Wallace, 
a bastard fever was distinctly recognized ; and as the season advanced, all the 
cases have been more characterized by depression and general typhoid symptoms. 
The cases of continued fever, with and without measly eruption, are becoming 
more common in Edinburgh, and also in Glasgow, as Dr. Wierofthe Hospital 
there informs me. 



1844.] Medical Pathology ayid Therapeutics. 223 

"If some think, that on this point there has been exhibited an undue reluc- 
tance to enter fully upon an important pathological inquiry, I beg to remind 
them that data are yet wanting to entitle us to discuss it fairly, and with profit. 
This may be attempted in a subsequent publication, at the close of the epidemic ; 
in the mean time let the remark of Rousseau be remembered, that ' the truth is in 
the facts, and not in the mind which observes them ;' and it is hoped, that some 
important facts have been even here communicated as contributions to this part 
of the pathology of the fever. 

♦' Severe vomiting is much more common^ as are likewise gastric, gasfro-hepatic^ 
gastro-splenic, and gastro-enteric symptoms, — Even in the mild cases, more or less 
pain of the epigastrium and vomiting are general symptoms. They have been 
urgent in the majority of those whom I have treated, both in the New Fever 
Hospital, and subsequently in the Infirmary. They have not always gone toge- 
ther; and even in some fatal caSes, in which the black vomit occurred, there 
was no pain or tenderness of the epigastrium. 

"In the mild cases, the matters vomited are generally the ingesta tinged with 
green, of various degrees of intensity. If the patient drinks incessantly, which 
is usual, the deepness of the green is less intense, from the immense quantity of 
fluid which is constantly being taken into, and at once ejected from the stomach, 
diluting the colouring matter ; for it is very common for every thing, as soon as 
swallowed, to be discharged. 

" In the most malignant of the yellow cases, there is sometimes a fine inky 
sediment in the vomit; at other times the grounds are grumous, — in consist- 
ence, like the thick part of hare soup, and varying in colour from dark-brown 
to black. In a fatal case which occurred to me the other day, there was a thick 
matter at the bottom of the vessel, resembling the dark-green mud which col- 
lects in pools of stagnant water. Upon repeatedly washing this sediment with 
water, the green colour was almost removed, and what remained was like the 
grounds of hare-soup. 

"The grumous matter of the black vomit, in its various forms, is unques- 
tionably blood extravasated from the capillaries of the stomach, and chemically 
altered by the action of the acids of the stomach upon it. That the black vomit 
is altered blood, has been again and again demonstrated at our autopsies, by 
tracing it to the sources of its extravasation, and finding large clots of blood in 
the submucous cellular tissue of other parts of the intestines in the same cases. 
The black colour is probably produced by chemical action between the acids of 
the stomach, and the iron of the blood." — pp. 103-8. 

" What is said by Blane of the affection of the stomach and vomiting in the 
yellow fever of tropical climates, applies to our present yellow cases. 'In all 
stages,' says he, 'of this disease, it is the affection of the stomach that affords 
the most distinguishing and important symptoms. As it advances, an uncon- 
querable irritability of this organ comes on. Whatever is swallowed, whether 
solid or fluid, of whatever quantity or quality, is immediately rejected by 
vomiting. An almost incessant retching takes place, even without any extra- 
neous irritation, which commonly on the third day ends in what is called the 
black vomit, the most hopeless of all the symptoms attending it.' 

"The acute pain which many patients complain of, when pressure is made 
over the stomach and duodenum, seems, in the majority of cases, to depend on 
flatulence alone. At all events, when accompanied by gaseous distension, which 
it generally is, I have found far more advantage derived from turpentine ene- 
mata, carminatives, and fomentations, than from leeches. 

"/'u/^ie.ss of the liver has been noticed during life, in several cases; but not so 
frequently as the same affection of the spleen. 

''* Congestion of the spleen has occurred in a considerable number of cases. 
From the great enlargement of the organ, and the pain which the slightest pres- 
sure over it excited, 1 at first treated the affection as acute splenitis, but more 
careful consideration has now induced me to regard it simply as a congestive 
affection; especially from the enlarged spleens which I have had an opportunity 
of examining after the death of the patients, presenting congestion only. The 



224 Progress of the Medical Sciences, [J"^y 

enormous congestion of this organ has as little to do with inflammation, as any 
of the other conirestions met with in the fever." — pp. 108-9, 

^^Gastro-enterilic symptoms are, in general, ohviously referable to the congested 
and irritated state of tlie mucous membrane of the stomach and bowels. There 
seems good reason, also, to believe, that in many cases they are aggravated by 
loose clots of effused blood, and the vitiated secretions themselves, which, act- 
ing as foreign bodies, tend still farther to increase the irritation. This accounts, 
probably, for the protracted diarrhoea in some severe cases which recovered. 
Much of the pain, however, which is complained of in the bowels arises from 
gaseous distension : we see it occurring, in some of the mildest cases, to a great 
extent. 

"A few other of the most important points in the pathology of the disease 
must be noticed. Those to which it is proposed to advert, are, 

" Is;^, The state of the blood. * 

"2flf, The origin and mode of propagation. 

"3c?, The structural lesions caused by the fever. 

"1. The state of the blood. — There seems good reason to believe, that a num- 
ber of individuals, who do not actually succumb under the influence of the epi- 
demic, are nevertheless affected by it in a marked and characteristic manner, 
such as by slight chills and sweatings, some headache and vomiting, with pros- 
tration of strength 

"That the blood really is in a dissolved state, was made perfectly manifest 
to us, frst, by the imperfect coagulation which it underwent when drawn from 
the veins of patients, a homogeneous spongy mass being formed, in place of a 
firm fibrinous clot, with a supernatent serosity; second, by the ecchymosis which 
was uniformly observed to surround flea-bites or other slight injuries of the 
skin; third, the frequent occurrence of purpurous spots; fourth, the haemor- 
rhages; and fflh, the discoveries made by the microscope. 

"Professor Allen Thomson had the goodness to lend me his able assistance, 
in examining the blood of a number of my patients, by means of the microscope. 
A few drops were taken from the ihumbs on Ihe same day (•34th Oct.), of about 
a dozen persons, some of them in the pyrexial, and others in the apyrexial stage 
of the disorder; and it was found, that in all of them there were an unusual 
number of pas globules; and in some cases, in addition to this, all the globules 
were found serrated and notched. 

"2. The origin and mode of propagation. — The disease is contagious. Of 
this we have sufficient evidence in the fact, that almost all the clerks, and 
others exposed to the contagion, have been seized. Dr. Heude, and his suc- 
cessor Mr. Reid, in the New Fever hospital; Dr. Bennett, my successor there; 
Mr. Cameron, and his successor Mr. Balfour in the adjoining Fever House; as 
well as most of the resident and clinical clerks in the Royal Infirmary, have 
gone through severe attacks during the past summer and autumn. Hardly any 
of the nurses, laundry-women, or others coming in contact either with the 
patients or their clothes, have escaped ; at one time there were eighteen nurses 
off duty from the fever; and of those who have recently been engaged for the 
first time, or of those who have hitherto escaped, one and another is from time 
to time being laid up. 

"It may be fairly objected, that while these illustrations incontestably prove 
that the disease is contagious, they do not give a fair view of the degree in 
which it is so, inasmuch as all the individuals specified were not only much 
exposed to the poison, but were also, from the laborious nature of iheir respect- 
ive duties, peculiarly predisposed to succumb under its influence. It is ad- 
mitted, that fatigue is a predisposing cause; and also, that the contagion is 
rendered infinitely more dangerous by the consortus segrotorum, even in well- 
ventilated fever wards, than it is in other circumstances. 

" Long-coniinued exposure to the poison seems also to operate most evidently 
against the chance of escape, as we find that comparatively few of the Dispen- 
sary medical officers and pupils — a very numerous class — have taken the dis- 
ease. These gentlemen are much exposed to the fever, and undergo a great 



1844.] Medical Pathology and Therapeutics. 225 

amount of fatiorne; but tliey are generally with their patients only for short 
periods, and have constant opportunities of inhaling an uneontaminated atmo- 
sphere. 

" I have seen and heard of a considerable number of isolated cnses, of various 
degrees of severity, in the best districts of the New Town, but have never yet 
known of an instance of the disease propagating itself in these localities. The 
same observation has been made by several medical friends, at whom I have 
made inquiries on tliis subject. That at a more advanced period of the epidemic, 
it may gain a footing in the New Town, would not be at all remarkable, con- 
sidering the unrestricted intercourse between the poor of the infected, and the 
wealthy of the uninfected districts. Besides, the midnight labours of the gay 
season will soon be in operation as a predisposing cause. 

"Those London physicians who have had the best opportunities of observing 
typhus fever, believe, that the poison in wliich it originates, does not extend for 
more than three or four feet from the patient; or, at all events, that at a greater 
distance, it becomes so diluted by the atmosphere, as to be innocuous. 

" It appears, that the contagion of the fever at present prevailing is subject to 
a similar law. 

'* From the number of laundry-women that have been attacked, it appears, 
that the clothes of our fever patients are especial repositories and communica- 
tors of the morbid poison. An interesting fact, which may be introduced here, 
as it is prohahly to be explained by what has just been stated, was communi- 
cated to me by Mr. Nicholson, from the island of Skye, one of my pupils. He 
informed me, that two reapers, who had had the fever in Edinburgh, arrived in 
his neighbourhood after their return home at the close of the harvest, when not 
a single case of the fever had been seen in the district. The mother of these 
persons, with whom they lived from the time of their arrival, was, in a few 
days, seized with the disease, and died. Other severe, and, in several instances, 
fatal cases occurred among the neighbours, who had waited upon her; and the 
disease is now spreading to such an extent over the whole territory as greatly 
to alarm the inhabitants. The people consider it a new pestilence among them, 
and are so dismayed at its appearance, and so afraid of its contagion, that they 
are ceasing to attend at church on Sunday. It is not, of course, to be supposed 
that all of the Skye cases have originated in the arrival of the two individuals 
referred to; because shortly after they returned, many others can)e back from 
their annual visit to the south, among whom were not a few who had been 
patients in the fever hospitals of Edinburgh and Glasgow." 

^'' 7'he post mortem oppearances were, 1. Abundance or even excess of bile, 
and a pervious slate of the biliary ducts; and 2. More or less congestion of 
organs, with frequently, extravasation of blood in various situations. 

"These appearances are either identical with, or analogous to, what the majo- 
rity of observers have noticed and described, as being those which are found in 
persons dying of yellow fever." 

" Seque/as.— These were, 1. A peculiar form of opthalmitis,* usually preceded 
by aniaurotic symptoms. 2. Glandular swellings. 3. Boils and cutaneous 
eruptions. 4. Etfusion into the knee-joint. 5. Swelled legs and ankles. 
6. Pain in the feet, with and without swelling. 7. Paralysis of the deltoid, 
and certain other muscles. 8. Sloughing of parts." 

Treatment. — Dr. Craigie, in an interesting paper on this disease, in the Edin- 
burgh Med. ^ Surs;. Journ., (^Oc\. 1843), says, "As to treatment in general, 
after the use of one or two doses of cathartic medicine, the patients were left 
very much to the efforts of nature. At first, when the increase in numbers 
showed the approach of an epidemic distemper, after the exhibition of cathartics, 
1 prescribed the use of the citrate of ammonia or saline julep with one grain of 
tartrate of antimony in twelve ounces of the mixture; and under this combina- 
tion the tongue became clean, the skin moist, and the pulse less frequent in the 
course of three or four days. I found, however, that so great was the tendency 

» * See preceding Number of this Journal, p. 480. : 



226 Progress of the Medical Sciences. [Ju^y 

to diaphoresis, that it was of little moment what was given, providing- uro-ent 
symptoms and uneasy sensations were alleviated. Thus pure water or toast- 
water appeared as efficacious in promoting diaphoresis and procuring sleep as 
any other means. The patients, however, often spontaneously requested cream 
of tartar water; and this, wiih a small proportion of carbonate of soda, to facili- 
tate the solution of the bitartrate, they got. In a very {ew cases was it requisite 
to apply leeches to the temples on account of the intensity of the headache. In 
general, when the hair was removed and cold applied, the pain rapidly subsided. 
When, after this, it did not, an active dose of cathartic medicine was adminis- 
tered. 

"At the crisis of the disease, when the sweatings were considerable, the 
weakness great, and rheumatic pains were excruciating, the best remedy I found 
to be the sulphate of quinine in two grain pills administered three, four, or five 
times daily. In some cases the debility was so considerable that it vi^as neces- 
sary to order small quantities of wine for a day or two, till the appearances of 
returning strength were manifest. 

" For the cases in which yellowness took place. It was difficult to say what 
treatment was best adapted. Those in whom it occurred were persons of de- 
ranged health, in general aged, always debilitated. In the most marked and 
severe case which recovered, that of Ann Campbell, the treatment consisted in 
the repeated administration of turpentine enemata, calomel and rhubarb by the 
stomach, the application of one large blister on the coronal and vertical region, 
and then of another on the occipito-cervical, and afterwards of castor-nil when 
the power of deglutition was restored. Wine was also allowed this patient at 
the rate of four ounces daily. Under this method of management the yellow- 
ness slowly and gradually but completely disappeared, sensibility and con- 
sciousness returned, and convalescence was eventually established, 

" In other cases, in which the yellowness, though general, was less deep in 
shade, and the nervous system was less strongly poisoned, calomel in doses of 
six grains, with one grain of aloes, once or twice daily, followed next morning 
by a dose of castor oil, was found sufficient to remove the symptoms. 

"Another remedy was tried by my assistant. Dr. Wood. This was the 
chloride of soda, in doses of twenty drops of the solution every second or third 
hour. Under its use the patients appeared to get rid of their symptoms in the 
course of two or three days, very much as by other means." 



SURGICAL PATHOLOGY AND THERAPEUTICS AND OPERA- 
TIVE SURGERY, 

30. Trousseau on the Prognosis of Tracheotomy in Croup. 1st. If the com- 
mencement of the disease dates several days back, if, consequently, the croup 
has advanced slowly, whatever may be the extent of the false membranes in the 
trachea and in the bronchi, the children either recover, or live at least several 
days. 

2d. But if the disease has been very rapid, even although, at the time of the 
operation, we ascertain that the false membranes do not extend beyond the 
larynx, the children die very quickly. 

3d. If, before the operation, the false membranes have been extended to the 
nose, if they cover the blistered surfaces; if the child is pale, somewhat bloated 
without having taken mercury or been bled, or if he has lost much blood, the 
operation has little chance of success. 

4th. If, before the operation, the pulse is moderately frequent, and if, after it, 
the pulse remains calm, hopes may be entertained. 

5th. If, immediately after the operation, the respiration becomes very fre- 
quent, the child either not coughing at all, or but very little, it is a bad sign. 



1844.] Surgery. 227 

6th. More boys than girls are cured. 

7ih. Children under two and over six years of aore rarely recover. 

8th. Caeteris paribus^ the danger is the greater, the more deeply the false mem- 
branes have extended. 

9th. ii" the child is subject to chronic catarrhs, and if he had been suffering 
from a cold for some time when he was attacked with croup, tracheotomy suc- 
ceeds better. 

10th. Even when all is going on favourably, great frequency of the respira- 
tion is a bad sign. 

11th. The more rapid and energetic the inflammation is, which attacks the 
wounds, the better are the chances of cure: the sudden sinking of the wound is 
a mortal sign. 

12th. There is never any thing to fear, as long as the respiration is silent or 
the noise is only occasioned by the displacement of mucosity ; but if the respi- 
ration becomes saiv-Iike {ser rati que), that is to say, is attended with a sound 
resembling that of a saw cutting stone, death is certain. 

13th. If a pneumonic or pleuritic attack supervenes, it is no reason to despair 
of the patient. 

14tli. Agitation and sleeplessness are bad signs 

15lh. If the wound becomes covered with false membranes, if, after with- 
drawing the canula, it remains gaping for a long time; if, after having entirely 
cicatrized, it reopens largely, the child is in danger. 

16th. The sooner the larynx is disembarrassed after the operation, the sooner 
may we remove the canula, the more certain and rapid is the cure. 

17th. If the croup supervened upon rubeola, scarlatina, variola or pertussis, 
although there is not ordinarily any connection between the malignantangina (1) 
and these different pyrexias, tracheotomy does not succeed. 

18th. If, the third day after the tracheotomy, the expectoration becomes mu- 
cous and catarrhal, the children recover. If there is none, or it is serous, or 
like little half-dried pieces of gum-arabic, they die. 

19th. If the patients react vigorously against the injections of water or of the 
nitrate of silver, and against the spongings-out, we should not despair, however 
fatal the other signs may be. 

•20ih. Children attacked with convulsions die, and the convulsions supervene 
oftener as the patients are younger, and as they have lost more blood before or 
during the operation. 

21st. When, after the tenth day, the drinks pass almost entirely from the 
pharynx into the larynx and trachea, even if they are easily rejected, the chil- 
dren most generally die. 

22d. The increase of the fever after the fourth day, agitation, sinking of the 
wound, and dryness of the trachea, frequency of the respiratory movements and 
attempts to cough, announce the invasion of pneumonia, which, at first lobular, 
becomes someiimes pseudo-lobar, and should be treated by the same means usu- 
ally employed against the pneumonia of children: we should exclude, however, 
blisters from the treatment, because they too often become covered with false 
membranes. — Mem. Sur. la Tracheoiomie^ vide Rilliet and Barthez, Traite des 
Mai. des Etifans, t. i .365-7. 

31. Tenotomy — its abuse, and the results. M. Malgaigne addressed to the 
French Academy of Sciences, Feb. 19, last, the following communication on the 
abuse and danger of tenotomy in certain deformities. It presents a picture of 
whai has been boastingly called the operative surgery of the day, little credit- 
able, we will not say to surgical science, but to the operators of the present day, 
and which, if we may judge from what has been enacted in this country, in no 
respect exaggerated. 

"The Royal Academy of Sciences was informed some years since of the 
alleged primary results of certain operations, marvellous in their nature, their 
innocence, and in the ultimate consequences which there was reason to 
hope they would lead to, or which it was said they had in some cases actually 



228 Progress of the Medical Sciences. ^uly 

led to. Thus, on January 20, 1840, there was communicated to the Aca- 
demy the history of a oirl, aged fourteen, in whom fifteen different tendons 
were divided at one sitting; and a few months later, this hardy proceeding was 
quite outdone hy another of the same i<ind, performed on a man, aged twenty- 
two, in whom fo7'fy -two muscles and tendons were divided, so to say, at once. 
In the first patient the ohject in view was to correct two incomplete luxations of 
the knees; and the day after the operation, this, it was said, was so completely 
effected, " that the only remains of the two deformities was a certain amount of 
permanent flexion of the joints." The nature of the deformity in the second 
case was not stated, and the result remained to be seen; it was promised that 
whatever it was it should be communicated to the Academy at a fitting time. 

*' Nearly four years, however, have now passed by, and that fitting time has not 
yet come, and I certainly should not have reminded the Academy of those un- 
finished cases, were it not that an attempt has been recently made to give cur- 
rency and credit to a surgical doctrine which seems to me fraught with most 
dangerous consequences, and respecting which the two facts above alluded to, 
together with some others, may tend to edify and instruct practitioners. The 
question is, whether it is allowable to divide tendons and muscles in deformities 
produced or kept up by paralysis, and without examining that question tho- 
roughly, I shall just state the results the practice has already led to. 

"The girl, aged fourteen, who had^/een tendinous sections first performed on 
her, and was subsequently subjected to five others, was an unfortunate paralytic 
inmate of Salpetriere, where she still continues. All her limbs were more or 
less contracted ; she was affected with club-foot, luxations of the knees, fiexion 
of the forearms and of the fingers; she presented an example of almost every 
variety of deformity, coupled with irremediable paralysis. The luxation of the 
knees was the first detormity attacked ; and whether it is that the operator 
laboured under some illusion, or that the luxations returned after being removed, 
certain it is that they exist at present. The club-feet were nextoperi\ted on, but 
they also remain at the present instant. One of the contracted hands was next 
dealt with ; and the operations were carried no further, merely because the pa- 
tient absolutely refused to submit to any more. 

"What has been gained by those twenty sections of tendons and muscles] 
Absolutely nothing. Sometliing, however, has been lost; for the patient expe- 
riences in both legs, at the point where tenotomy was performed, acute pain from 
which she did not previously suffer; before the operation on the right hand she 
was able to work at her needle the entire day, but now she is unable to work at 
all. She left the orthopedic wards of the Hopital des Erifans, 29ih June 1840, 
and two months after this first experiment, the second was instituted on the young 
man, aged twenty-two, above mentioned. 

"This patient was even more impotent and paralytic than the other; all his 
limbs were bent, and it was proposed to straighten them all. Despite all my 
researches, I could not accurately ascertain how it has fared with this patient. 
Every one knows of the operation, but then the results have been carefully con- 
cealed from every one. I shall not allude to the various reports circulated on 
the subject, as I wish to confine myself to what is accur.itely true. 

" But we have the complete history of a similar operation performed in a simi- 
lar case by an honourable and conscientious surgeon. The patient was a child, 
aged 11, affected with paralysis and contraction of all its limbs, but at least re- 
taining the power of inclining the trunk forwards, backwards, and to each side. 
M. Phillips, misled by the example set him, divided all the contracted tendons, 
straightened all the flexed joints, and the result was, that the unfortunate child, 
straight as a bar of iron, the arms glued against the trunk, lost the limited power 
of motion formerly possessed by the entire body, and lies on the bed like a dead 
body, the head alone enjoying motion — a frightful picture on which the mind is 
unwilling to dwell. 

" Between the 1st of August, 1839, and the 1st of July, 1843, six patients 
affected with paralysis, more or less complete, have been admitted into the ortho- 
pedic wards of the Hopital des Enfans. In four of the cases there seems to 



1844.] Surgery. 229 

have been g-eneral paralysis. One was the g^ir! whose case has heen already 
alluded to; a second remained in hospital six days only; the two others died in 
the hospital. In the two other cases the paralysis only affected the foot or the 
lower extrennities ; one I have been nnable to trace; in the other the tendo- 
achillis was divided, but the club-foot and paralysis remain as beforer 

I thoncrht it important to communicate these results to the Academy, as it was 
to this learned body that such contrary results were partly announced, and partly 
promised. Ii is time tiiat a due estimate should l)e performed of these hazard- 
ous attempts, and I intend shortly to address anotiier letter to the Academy on 
the abuse and danger of myotomy in the treatment of lateral deformities of the 
spine. 

32. Ununited Fracture of the Forearm successfully treated hy seton. By Dr. 
Houston — A woman, selat. 26, had her forearm fractured on the 17th March, 
1843, by her arm beinor accidentally drawn in and squeezed between a wheel and 
a belt which she was adjusting together. The bones were both broken at the 
same place, and about the centre of their length. 

The fracture was set by a medical gentleman at the time, and put up with 
splints and a bandage. These dressings were left on, without being changed, 
for five weeks, during which she suffered much uneasiness in the arm. At 
the expiration of that period, the fracture was found ununited, and the hand numb 
and incapable of motion. 

'I'he splints were theri reapplied, but after further suffering for some weeks, 
and finding no advance towards union, the woman returned to Ireland. 

On admission into the city of Dublin Hospital, (ten months from the date of 
the accident,) the fracture was quite loose, admitting of nearly as much motion 
as the wrist-joint. The inferior fragments lay on the back of the superior, over- 
lapping them for about three-quarters of an inch. The hand and forearm were 
wasted and pou'erless, and sudden motion of any kind, or change in the weather, 
produced distressing pain. There was no tumefaction or lumpishness about the 
fracture, such as is usually present when callus has been secreted; on the con- 
trary, the ends of the bones appeared rather to have undergone atrophy than 
enlargement. This young woman never had had any syphilitic or other serious 
indisposition. The great length of time during which tlie fracture had been 
ununited rendering it unlikely that the milder means of treatment, such as mer- 
cury, friction of the bones, or even the process of scarifying them by subcuta- 
neous sections lately recommended, would effect a cure, and the operation of 
sawing off the ends of the bones being regarded as too severe an experiment for 
a first attempt, the intermediate method, that by seton, was determined on. 

On the 10th of January, 1844, Dr. Houston, assisted by Professors Hargrave 
and Williams, introduced three setons, consisting each of ten or twelve silk 
threads, in the following manner. The bones being pulled a little asunder, a 
strong seton needle, armed wiih the silk, was pushed obliquely between the 
overlapping surfaces of the fracture in the radius, and the seton, drawn after it, 
left lying directly between the bones. In the same way, another seton was 
placed between the overlapping ends of the ulna. And, finally, in order to 
insure a sufhcriency of inflammatory action, a third seton was introduced around 
the outside of the broken part of the radius, as close to the bone as possible, by 
means of a more curved needle than that used in the other instances, (^are was 
taken in the introduction of these needles to avoid the line of the principal 
vessels and nerves; and small incisions made with a lancet through the skin at 
the points of their entrance and exit were found to facilitate greatly the passage 
of the setons through these apertures, and to save the patient from much pain. 
The limb vvas then enveloped loosely in a bandage, and laid on a splint. 

The next dviy the forearm was swollen and painful, and the pulse 90. The 
patient had slept badly, and complained of headache, thirst, and heat of skin. 
An aperient draught and a cooling lotion were directed. 

On the third day purulent matter escaped at the seton-holes. During a period 
of three weeks, the limb was kept steadily in splints, the dressings being re- 
No. XV.— July, 1844. 20 



230 Progress of the Medical Sciences. [Ju^y 

moved daily, to afford an opportunity for washing away the discharge, which 
was abundant. The setons were then withdrawn by decrees, a few threads 
beincr pulled out at each dressing, so that by the 6th of February all had been 
removed. The linab was now found to have acquired considerable firmness. 
The woman could raise and move it without the same yielding at the broken 
part as formerly. However, as it was very tender, no attempts were made to 
ascertain the exact amount of solidity which it had gained. The tumefaction 
was at this period limited to the immediate neighbourhood of the fractures, 
where there was a palpable enlargement of the bones. 

On the Uth of February, at which date the seton holes had completely 
healed, the arm was put up, immovably, in the following manner. A dry roller 
was applied round the arm, from the thumb upwards, equably and with mode- 
rate tiglitness. A layer of starch was rubbed well on the outside of this. Then 
the roller was carried down again, and again smeared with starch. Two pieces 
of pasteboard, cut to the shape of the forearm, were now laid on, one before, 
the other behind, and fixed in their places by several additional layers of the 
roller, laid on and starched as the first had been. The pressure exerted was 
barely such that while the bones were steadied properly, the muscles were 
allowed sufficient play to permit them to move the fingers a little. This dressing, 
by the next day, had become as firm as a board : and the only unusual sensation 
the patient experienced from it was a continual glow of warmth in the limb to 
the extent embraced by the bandage. During the entire period that this woman 
was under treatment, with the exception of the first week, when there was con- 
siderable local inflammation and general febrile disturbance, she was kept on 
full diet, and allowed a little wine or porter every day. She had also directions 
to remain out of doors, as much as the weather would permit, walking in the 
garden of the hospital. 

On the 7ih of March, four weeks from the application of the fixed bandage, 
the arm was again unrolled, when it was ascertained that the desired union had 
been established, that the patient could flex and extend the arm, and perform 
the motions of pronation and supination with facility, and that attempts to bend 
the bones at the broken parts, although productive of pain, made no impression 
on their form. The arm v^-as now left unbandaged, and treated simply by 
bathing, hand-rubbing, and passive motion ; and every day it gained in strength 
and fulness. On the 12th of March, the starch bandage was again applied 
preparatory to the woman undertaking a journey home, into the country ; and on 
the 13th she was discharged, with directions to keep the dressings on for a few 
weeks longer, to permit the tenderness to subside, and to give full security 
against the occurrence of any morbid degeneration of the callus. 

On the 10th of April, Dr. Houston received a letter from Dr. Fleming, inform- 
ing him that "the union was quite perfect, and that the woman was daily ac- 
quirinn a better use of the muscles of the arm." 

Dr. Houston said that he thought this case calculated to encourage the prac- 
tice of treating such lesions by seton — or, at least, of making the attempt before 
proceeding to the more severe alternative of extirpating the ends of the bones — 
an operation which is not only tedious and painful in the extreme, but also 
fraught with danger to the life of the individual. — Dublin Med. Press, May 1, 
1844. 

33. Aneurism of the External Iliac Jlriery — Ligature of the Common Iliac. By 
Richard Hey, Esq., of York. — The subject of this case was a man 41 years of 
age, who, on the 10th of November, 1843, perceived a stiffness and uneasiness 
in his left groin, and on examination found a small hard tumour immediately 
above Poupart's ligament, midway between the anterior superior spinous pro- 
cess of the ilium and the tuber of the pubis. Having been occasionally subject 
to scrofulous tumours, ending in suppuration, he supposed this to be an enlarged 
gland, and therefore at first took but little notice of it; he showed it, however, 
to his medical attendant, who prescribed suitable remedies for its removal. On 
the 13th he was suddenly attacked with severe pain in the tumour, and on the 



I 



1844.] Surgery: 231 

following- morning- it was found to be much increased in size; and now, for the 
first time, a decided pulsation was observed in it; pulse 90. From this time 
until the 22d, the tumour made perceptible advances in size daily, accompanied 
with pain along the course of the anterior crural nerve. 

November 22. The tumour is now the size of a pretty laro-e orange; the 
impulse very strong. It was, however, easily emptied by moderate and con- 
tinued pressure, instantly filling again when the pressure was removed. Pres- 
sure on the aorta had the same effect, but in a lesser degree. When the base 
was grasped, the fingers at every pulsation were forcibly separated, and equally 
so on every side. Tliere was clearly aneurism of the external iliac artery. 
, Novemher 28. The tumour rapidly increasing in size, and as there seemed to 
be no alternative but placing a ligature upon the common iliac artery or speedy 
death, Mr. Hey proposed the operation, but the patient would not then consent. 

November 30. The tumour now, from having a round and uniform surface, 
has become conical like the pointing of an abscess, the skin also thinner, red, 
and shininff. 

December 2. The tumour has so much increased within the last forty-eight 
hours as to render any farther delay hazardous. Mr. William Hey, of Leeds, 
saw the patient in consultation, and concurred in the propriety of placing a 
ligature on the common iliac artery. "It seemed out of the question to attempt 
tying the external iliac, because fronn the very large size and extent of the sac, 
it was evident that there would not be room for a ligature between that and the 
bifurcation of the external and internal iliacs; and in addition to this, the pro- 
bable Slate of that artery made it unwise to run such a risk, even if it had been 
practicable. 

" December 3. The tumour now occupied the whole of the left iliac fossa, its 
base projecting considerably below Poupart's ligament inferiorly, and superiorly 
extending to within less than an inch and a half from the navel, being- six inches 
across from above to below, and six inches and a half from side to side; pro- 
jecting also from the plane of the abdomen fully three inches. 

"The patient was placed on his back on a mattress, his shoulders moderately 
raised. The incision was commenced two inches and three-quarters above the 
navel, and exactly three inches to the left of the median line. This was carried 
down moderately curved to the base of the tumour about six inches, and was 
afterwards enlarged by an angular continuation, one inch and a half in length. 
The fibres of the external and internal oblique muscles and transversalis being 
successively divided, the transversalis fascia was readily raised by means of a 
director, and carefully opened out through the whole length of the incision. 
The peritoneum now protruded in some measure; it was, however, kept down 
■without much difficulty; and being gently drawn towards the opposite side, I 
was enabled slowly to insinuate my fingers behind the peritoneum, gradually 
separating it from its cellular attachment to the parts beneath. The common 
iliac artery was easily reached, and upon compressing it with the fingers, the 
pulsation in the tumour ceased at once. A little time was occupied in scratch- 
ing through the sheath of the artery with the point of the aneurism needle; this 
being accomplished, the needle was passed under the artery from within out- 
wards, armed with a double ligature of staymaker's silk, waxed. By holding 
aside ihe peritoneum and viscera, we now obtained for a moment a view of the 
artery, and ascertained that nothing else was included in the ligature; this being 
tied with the fingers close down upon the artery, all pulsation in the sac entirely 
ceased, and never afterwards returned in the slightest degree. The exact posi- 
tion of the ligature was, I believe, an inch below the bifurcation of the common 
iliacs. Tiie wound was closed with six sutures and strips of adhesive plaster; 
and over the whole a coating of lint dipped in strong mucilage. Time, 25 
minutes. The patient was now a good deal exhausted, although so little blood 
had been lost that it had not been necessary to take up a single bleeding vessel; 
he vomited also some brandy and water which had been given to him during the 
operation. He took, however, a cup of boiled milk, which was retained. 

" Evening. — Patient had been very restless and uneasy after the operation for 



232 Progress of the Medical Sciences. [J"^y 

some hours. A camphor draught, with 25 drops of Battley's sedative, had had 
the effect of composino- him. There was now moderate reaction, pulse 90. 
The wound continued still very uneasy. 

"Monday, December 4, half-past 9 A.M. Has passed a tolerahle night, 
having had sleep at intervals without any further opiate. Pulse 95, rather irri- 
table; bowels not moved, but distended with flatus; hiccup; no pain. Two 
grains and a half of calomel, and a quarter of a grain of opium, to be taken 
immediately, and in two hours time half an ounce of castor .oil in peppermint 
water. P'arinaceous diet. 

" Half-past 7 P. M. Patient looking very ill; countenance anxious and sunken. 
No action of the bowels; a second dose of the oil had been rejected; hiccup 
increased ; body very tympanitic and uneasy. The bandage round the body 
was slackened, with some relief. Great thirst, and difficulty in making water. 
Pulse 98. An enema consisting of gruel, with two scruples of gum assafcetida, 
immediately; small doses of liquor ammonias acetatis, occasionally. 

"Tuesday, December 5, 10 A.M. Had intervals of light but refreshing 
sleep during the night. Enema had produced one good evacuation with much 
relief. No tenderness on pressing the abdomen; pulse 98. Patient upon the 
whole in a satisfactory state. 

"Fespere. Nut quite so well; rather more feverish; pulse had risen during 
the day to 104, now 100, and not so soft; tongue dry. No evacuation from the 
bowels; urine high coloured. Restless. Calomel, one grain; compound ipe- 
cacuanha powder, two grains. To be taken every three hours, with an effer- 
vescing saline draught. A common enema in the morning. 

"Wednesday, December 6, half-past 9, A. M. Had passed a tranquil night; 
refreshing sleep. Enema had acted well; body soft and flaccid; pulse 89, soft. 
Dressed the wound, which showed a great disposition to heal ; discharge very 
moderate. Omit the calomel ; continue the saline draughts and farinaceous 
diet. 

"December 7. Nothing material; all going on well; pulse 80. Bowels 
moved tliree or four times yesterday. Patient allowed some beef-tea and arrow- 
root, mixed. During the last day or two the tumour had looked very threaten- 
ing and ready to suppurate. 

"December 8. Dressed the wound, which upon the whole was going on 
well. Body distended; but little pain. On this day the tumour seemed to be 
slightly diminished in size; the skin a little paler and shrunk. 

" December 9. Going on well in every respect. Hard lumps discharged from 
the bowels; appetite good. Ordered a mutton-chop and half an ounce of wine, 
in addition to arrow-root, with beef-tea. 

" December 10. Wound looking well, though the edges not quite so united ; 
discharge very moderate; bodily health and strength better than before the 
operation; enjoyed his chop and wine yesterday; pulse 80. Discovered this 
day, for the first time, an artery on the dorsum of the foot, pulsating, (the ante- 
rior tibial). Tumour decidedly diminished. From this time nothing particular 
occurred during the progress of the case. It was found necessary to give a 
small dose of morpliia every night, without which he had little or no sleep. 
He also suffered much from violent spasm of the bowels, and tenesmus when- 
ever they were moved, in consequence of which he had medicine only on alter- 
nate days. As the motions were abundant in quantity it did not seem very 
evident from what this distressing symptom arose; the spasm, however, could 
not be quieted without the aid of an opiate injection. 

" December 23. Tumour has diminished more than one-half, but the ligature 
quite fast; appetite good. 

"December 30. On removing the dressings this day the ligatijre seemed to 
be lying somewhat further out of the wound than usual, and on gently drawing 
it, I found it quite loose, and it came away without the slightest pain or diffi- 
culty. The length of the ligature from the knot to the surface was nearly five 
inches. 

"January 4. I must now allude more particularly to the distressing feature 



1844.] Surgery. 233 

which has already been mentioned, and which threatened, if not overcome, to 
render our patient's life miserable, viz., the spasm of the bowels. Thinking 
that it might arise from some obstruction in the rectum, I had recommended Mr. 
Nelson to pass a bougie and explore the lower bowel : this he did, without, 
however, any result. In the mean time the spasm became more and more urgent 
whenever the bowels were moved. However copious the evacuation, he always 
felt as though there was something left which could not be expelled. On this 
day matters assumed a very serious aspect, the bowels were completely ob- 
structed, the spasm dreadful ; at length he became quite exhausted, and seemed 
to be falling into a state of coma, body very tympanitic. On passing the 
catheter to ascertain if the bladder were distended, Mr. Nelson found consider- 
able obstruction. This led him again to examine the rectum, which he now 
found to be enormously distended with a hardened mass of faeces. It felt, he 
said, more like a child's head presenting than any thing else he could compare 
it to. It was thoroughly dry like bran. Here then was the cause of these 
formidable symptoms. It appears that the pressure of the increasing tumour 
had caused a gradual accumulation of fasces in the colon; and although con- 
siderable evacuations were obtained by means of aperient medicines and injec- 
tions, yet there never was a complete clearance, owing to the growing pressure 
of the sac. As this however became gradually diminished by absorption, it 
permitted the fscal matter slowly to advance, and at last completely to block 
up the rectum in the manner already described. That this was not discovered 
when Mr. Nelson first explored the rectum was no fault of his, but arose, I 
doubt not, from the circumstance that it had not descended within reach of an 
ordinary bougie. 

" Mr. Nelson happily succeeded in breaking down this extraordinary accumu- 
lation, and our patient in a few hours so far revived as to relieve us from our 
gloomy anticipations. Nothing has since occurred to retard his complete re- 
covery. 

*'It now only remains to notice one point, viz., the temperature of the limb 
after the operation. Perhaps this ought sooner to have been alluded to, but in 
truth there is little to say on this part of the case. We kept an accurate account, 
but after the first few days the temperature of the two limbs was so nearly 
equal that the difference did not amount to half a degree. The limb was 
simply wrapped in fine flannel. The temperature at first fell not quite so much 
as three degrees below that of the sound limb; in forty-eight hours it had risen 
two degrees above the opposite; this soon subsided, and in four days after the 
operation the two limbs were equal (89°) and continued so. 

"Two or three weeks after I had taken my leave, Mr. Nelson informed me 
that the sinus, made by the ligature, v/as not healed. It appeared that the sac 
had ulcerated and discharged its remaining contents, grumous blood mixed with 
pus; by this means what remained of the tumour was entirely dispersed, and 
the sinus healed. We thought it advisable to apply a belt afterwards, in order 
to support the weakened parietes of the abdomen; and to the most prominent 
part, also, a kind of truss, with a four inch pad, which the patient found very 
comfortable. 

"A remarkable feature in this case was the extreme and unusual rapidity of 
its progress, after its first commencement, only three weeks having elapsed 
from its first appearance of the size of a hazel nut, before it had attained the 
formidable size which has been described." — Prov. Med. and Surg. Journ., May 
1, 1844. 

34. Removal of a knife-blade from behveen the Trachea and right Carotid 
'Artery. By R. T. Hunt, Esq., of Manchester. — A man was wounded in the 
neck, whilst on the ground, by another who had knocked him down and fallen 
on him. The surgeon who first examined the wound could find no foreign body 
in it. Three weeks afterwards the patient applied to Mr. Hunt, at which 
period he was sulTering from urgent dyspnoea, oppression and tightness of the 
chest, and fixed pain of the right side, extending through to the inferior anp-!e 

20* 



234 Progress of the Medical Sciences. [July 

of the scapula. His face was flushed, his pulse quick and throbbing, and he 
could not lie down. 

There was a recent cicatrix about an inch above the interclavicular space, 
which felt much indurated, and my impression at the time was, that the tracheal 
cartilages had been lacerated, and had united very unequally. Mr. Hunt bled 
him to 12 ounces from a large orifice, and complete syncope followed. When 
he recovered from the fainting-, the breathing was much freer, and he felt 
relieved. He was treated with mercurials, hyoscyamus, and common aperients, 
and continued improving, but the fixed pain in the thorax did not entirely 
subside. 

A week afterwards he called on Mr. H., and stated that something had made 
its appearance in the situation of the wound. Upon examination, Mr. H. found 
the cicatrix ulcerated, so as to expose a black angular metallic substance which 
was so impacted as to require careful dissection for its removal. It proved then 
to be a knife-blade 2^6_ inches long, ^^ inches wide, and jL inches thick at back. 
When the blade was withdrawn, it apparently rested obliquely against the body 
of one of the cervical vertebras, and its back W'as directed backwards and 
upwards. The bluntness of this point and of the edge of the knife will account 
for the carotid and other important structures so fortunately having escaped 
being injured. 

An opiate was given, rest and an antiphlogistic regimen enjoined, and in ten 
days he perfectly recovered.— i6tc?., 24ih April, 1844. 

35. Intra-capsuJar Fracture of the neck of the Thigh-Bone, — Mr. W'illiams 
exhibited to the Surgical Society of Ireland, April 27, 1844, the femur of a 
patient aged 52, who had been admitted into the City of Dublin Hospital with 
intra-capsular fracture of the neck of that bone, and had lived exactly sixteen 
days after the accident. He had died in consequence of disease of the thoracic 
viscera, having been affected with unusually extensive emphysema of both 
lungs, general bronchitis, and several tubercular cavities towards the apex of 
each lung. On laying open the joint, it was observed that there was very little 
synovia indeed in the interior of the joint, but it would be there seen that the 
secretion of synovia was replaced by the secretion of organizable and organized 
lymph which coated the entire articular surface of the capsular ligament. This 
lymph was firm^ adhered closely to the ligament, and was vascular thronghout, 
though more highly organized in some situations than in others ; but this lymph, 
and this he (Mr. Williams) thought particularly interesting, was also adherent 
at several points to the neck and head of the femur. Those adhesions, it was 
true, were not very firm, and in the manipulations necessary for inspecting the 
interior of the joint, they had been detached, but nevertheless, traces of their 
existence could still be recognized, l^he situation in which the capsular liga- 
ment adhered through the medium of this lymph most extensively and most, 
firmly to the bone was at some points of the broken edge of the inferior frag- 
ment, especially anteriorly, to the extent of a quarter of an inch, and at this 
point the broken edge of the bone was rounded and smooth, contrasting strongly 
with the rough sharp edge of the bone in the situations where no such adhesions 
had existed. On placing the capsular ligament in situ, it would be observed 
that the situations in which the lymph that coated its inner surface was most 
abundant and most vascular, were precisely the points at which it adhered to 
the bone. The capsular ligament, independently of being thus lined with lymph, 
was somewhat thickened ; in fact, it seemed to have acted the part that the 
periosteum often, perhaps, usually acts in fractures of the shafts of the long 
bones. With respect to the fracture itself, it was entirely intra-capsular, and 
ran in the direction which he thought these fractures very usually did. It 
commenced very near the head of the femur, and ran in a slightly curved line 
from above downwards, and from within outwards, until it arrived at the com- 
pact structure of the neck of the femur inferiorly, where it ran very obliquely 
outwards and downwards, thus leaving attached to the upper fragment in this 
situation a sharp wedged-shaped piece of the compact tissue of the bone which 



1844.] Surgery. 235 

seemed to project against and alnnost threaten to tear the capsular liVament of 
the joint at its most depending- point. The reflected ligament that covers the 
neck of the femur was but partially torn through, indeed about one-half of it 
on the inferior and posterior aspect of the neck of the femur remained intact. 
There were no adhesions between this reflected ligament and the capsular liga- 
ment. On inspecting the broken surfaces of the bone, it would be seen that 
they were both highly vascular, and there really seemed to be little, if any, dif- 
ference in this respect between the surface of the lower and that of the upper 
fragment, at least so far as could be at present determined, Tor he had abstained 
from separating them so as to examine them fully, lest he might completely 
destroy what he considered it very interesting to see — several shreds of lymph 
which passed between the opposed broken surfaces, perpendicular to and adhe- 
rent to both surfaces— several of these thread-like bands of lymph had been 
unavoidably broken, but some of them were still distinctly seen on gently sepa- 
rating the edges of the fracture. This appearance showed that a thin layer of 
lymph had been effused between the opposed surfaces of the fracture, on sepa- 
rating which it was drawn out into the thin bands or threads then seen. The 
investing cartilage of the head of the femur showed slight recent absorption 
at some points, especially anteriorly, and it was at these points that the capsular 
ligament, as already observed, had been adherent, though very feebly, it was 
true, to the head ol the bone. The round ligament was unusually large and 
very vascular. From the appearances in the joint, Mr. Williams thonglit that 
this was a case in which perfect bony union of an intracapsular fracture of the 
neck of the femur might very probably have ultimately taken place under more 
favourable circumstances; at all events, it could scarcely be doubted that, had 
the patient lived, most useful union would have occurred. He might say just 
thus much with reference to the history of the case, that the patient walked 
thirty or forty yards after the accident, yet the fracture was not impacted, but 
had the joint been examined at a remote period, when union, whether bony or 
not, had occurred, it would, he thought, be pronounced to have been an impacted 
fracture. In order to have a term of comparison, the opposite femur had been 
removed, and in both bones similar senile alterations had evidently commenced, 
the neck of the femur being shorter than natural, and on the unbroken bone 
(though not on the fractured one) the cartilage of incrustation was beginning to 
sustain senile absorption or usure at two distinct points. The patient, however, 
had not suffered from pain in either hip, or been lame prior to the accident, pro- 
bably because the commencing affection of the cartilage occupied not the upper 
part of the head of the femur, but the anterior part, where it was subject to little 
pressure. The attempts at reparation in this case did not depend on any parti- 
cular care having been taken in the treatment of the fracture; for the first two 
days splints were applied, but the embarrassment of respiration then rendered it 
imperative to remove the apparatus in order to allow the patient to sit up and 
have his position frequently changed. 

The fracture had been caused by a fall directly on the most prominent point 
of the trochanter major. 

This case disproves one of the positions on which a recent writer, M. Rodet, 
lays great stress. He maintains that intra-capsular fractures only occurred from 
violence applied in the direction of the axis of the femur, as in falls on the foot, 
or from what he terms antero-lateral falls, in which the anterior part of the great 
trochanter comes on the ground ; that if the fall be postero-lateral, the fracture 
will be mixed, or both within and without the capsular ligament; but that direct 
lateral falls must produce extra-articular fractures. The direction of the violence 
was to be ascertained, not merely from the account of the patient, but by exa- 
mining the hip, and ascertaining the exact situation of any contusion which M. 
Rodei deemed a certain sign of the nature of the fracture. Now, in this case 
the fracture had been regarded as intracapsular on the patient's admission into 
the hospital, and especial care had been taken to examine the hip, with reference 
to the views of M. Rodet, whose paper he (Mr. Williams) had shortly before 
read: there was little contusion, though the trowsers were torn; but still there 



236 Progress of the Medical Sciences, [July 

was a distinct abrasion of the skin over the most prominent and external part of 
the trochanter major; and if there was any deviation whatever from a directly 
lateral fall, the deviation must have been slightly posteriorly, as the man's 
Irowsers were covered with dust behind the torn part; but this probably arose 
from his having rolled backwards after the fall. The patient himself could not 
say whether he had fallen backwards or a little forwards, or exactly on his 
side; but the contusion which M. Rodet regarded as a diagnostic sign was 
there, and showed that the force was applied in a direction which he maintained 
must produce an exl!^a-articular fracture, and yet dissection showed that the 
fracture was completely intracapsular, and thus this case clinically disproved 
M. Rodet's very ingenious, geometrical, and mechanical speculations, and 
deprived his alleged diagnostic sign of all its value. It might be said that the 
neck of the bone was somewhat altered in this case, and that M. Rodet admitted 
that such alteration might modify the results; but then in many, perhaps in 
most cases of<lractured neck of the femur, the bone was altered, at least as much 
as in this instance, so that M. Rodet's sign thus again lost its value. As to 
there being no synovia in the joint, it was necessary to mention that circum- 
stance, both as it was the fact, and because many eminent men mentioned inor- 
dinate secretion as the constant result of intracapsular fractures in the early 
stages of the accident. — Dublin Med. Fress, May i5lh, 1844. 

36. Process of reparation of fractured bone. Mr. Williams exhibited to the 
Surgical Society of Ireland March 30, a preparation which he conceived to be 
interesting as affording an opportunity of examining a simple fracture during 
the process of reparation and besides illustrating one or two points of some im- 
portance. The subject of the accident was an old man, aged about seventy, 
emaciated and apparently of feeble constitution. The fracture was the result of 
direct violence, having been caused by the wheel oi a car passing over the left 
femur, which was fractured at, or rather a little below, the point of junction of 
the middle and lower third of the shaft of the bone. He was brought to the 
City of Dublin Hospital on the 20th of January, and died on the 18th March, so 
that he lived fifty-seven days from the receipt of the injury; after such a period 
the formation of callus would, in a younger person, have been probably seen in 
a more advanced stage; but before drawing the attention of the society to the 
appearances actually exhibited in the preparation, it would be well to state, very 
briefly, some of the more prominent circumstances connected with the case 
during life. It was quite unnecessary to give any thing like a detail of the case; 
but a few observations were necessary. Thus it would be observed that the 
broken extremities of the bones overlapped each other considerably, to the ex- 
tent, indeed, of nearly three inches. The reason of this was, that seeing the 
advanced age and debility of the patient, no attempt was made to treat the frac- 
ture by permanent extension in the straight position of the limb. The limb 
was, in the first instance, placed on the double inclined plane, and every possi- 
ble care was taken to prevent the formation of bed-sores ; the patient was, after 
the first few days, when the swelling and tension of the thigh had subsided, 
supported in the sitting posture on the side of the bed, the limb on the inclined 
plane being carefully slid out on a platform, and as a sore, nevertheless, began 
to form over the sacrum, and gangrenous phlyctenas ap{)eared on the toes of both 
feet, of the uninjured as well as of the fractured limb, he was soon transferred 
to Dr. Arnott's hydrostatic bed, but ultimately died in consequence of extensive 
sloughing over the sacrum. Had any attempt therefore been made to permanently 
reduce and coapt the fracture in the usual way, the fatal termination of the case 
would have been greatly accelerated, and hence the very considerable degree of 
overlapping observable in the present case. About fourteen hours after death 
the limb was examined. There were some remains of ecchymosis between the 
integuments and fasci lata on the front and external surface of the limb ; the 
muscles presented a natural appearance, except in the immediate vicinity of the 
fracture, where they were still slightly infiltrated with blood. The fracture was 
oblique from above downwards, and from before backwards, and slightly from 



1844.] Surgery. 237 

■within outwards. The inferior extremity of the upper fragment was displaced 
a little forwards and outwards, and the upper extremity of the lower fraorment 
consequently lay somewhat internal and posterior to the upper portion of the 
bone. He (Mr. Williams) would first heg' the society to inspect the vertical 
section he held in his hand of the broken extremity of the inferior portion of the 
femur; it would be observed that on the internal surface of the section callus 
was obviously deposited between the periosteum and the bone; the periosteum 
was somewhat, but not much thickened, and showed some slight marks of in- 
creased vascularity. On the external surface of the same section, however— that 
is to say, on the aspect of the fracture, which, thongh not in contact with, yet 
corresponded to the inner surface of the upper fragment of the femur, the callus 
or new bone was deposited in quite a different situation ; here there was no 
bone whatever formed between the periosteum and the old bone, but there was 
an abundant formation of callus external to the periosteum, deposited on its 
outer surface and in the muscular and other tissues intervening between the two 
overlapping portions of bone, and the new bone thus deposited in the heteroge- 
nous tissues external to the periosteum had extended nearly to, but not quite in 
contact with, the surface or the periosteum of the overlapping upper fragment. 
In order to make the matter clearer, this vertical section of the semi-diameter of 
the bone had been detached transversely hy the saw, and here, on the one side, 
the periosteum could be clearly traced over the newly-formed bone, while on the 
other, or outer side, facing the upper or overlapping fragment of the femur, the 
periosteum was clearly traceable between the femur and the newly-deposited 
bone, while not a particle of callus was deposited at this side beneath the perios- 
teum — that is to say, between that membrane and the original bone. If the 
upper portion of the femur is now examined, we find a very different condition 
of things; in it there is no attempt whatever at osseous reparation, so far from 
it that, on the contrary, there is actually atrophy of the extremity of the bone; 
thus the transverse diameter of the femur is diminished from within fully an 
inch of its broken extremity, so that the bone tapers off in a conical shape, and, 
moreover, the medullary canal is considerably increased in breadth, and thus 
the actual quantity of bone in the upper portion of the femur is greatly dimi- 
nished, while no new bone is deposited. Mr. Williams said that he thought this 
remarkable difference in the condition of the two fractured extremities of the 
femur was explained by the situation of the fracture, which had occurred about 
half an inch above the entrance of the great nutritious artery of the femur, which 
might be seen here, and as it seemed to him of remarkably large size. Here it 
was entering the lower fragment about half an inch below its broken extremity, 
which was thus suitably supplied with blood; the parts could therefore generate 
new bone, while the deficiency in this respect, in the upper fragment, might be 
partly, at least, referable to the supply of blood from this artery being cut off by 
the complete rupture of the nutritious artery of the bone. The condition of the 
tissues between the overlapping portions of the bone should be mentioned; the 
cellular tissue was more developed and denser than natural, and much of the 
muscular tissue seemed absorbed, at least it was intersected with fibrous or eel-- 
lulo-fibrous septa, rendering the entire of the connecting medium between the 
overlapping portions of bone dense, resisting, and apparently in a transition 
state, into a fibrous or fibro-cellular tissue. In this dense structure, as already 
particularly remarked, new bone had been at the upper part deposited, and that 
to such an extent, that, had the patient lived, bony union might, Mr. Williams 
thought, have been effected, notwithstanding the impossibility of keeping the 
opposed surfaces of the overlapping bones in close and firm contact. He (Mr. 
Williams) would just observe that he thought this preparation, in the first place, 
showed that the formation of bone is not limited to any particular tissue, that, as 
his friend Dr. Macdonnald and others maintained, whenever deposition of bone 
is effected, it is by the nutritious vessels of the part in which the bone is re- 
quired to be deposited acquiring the power of secreting bone. In the present 
preparation the deposition of bone was quite irrespective of tissue, but was en- 
tirely subordinate to a due supply of blood; this preparation, therefore, he 



238 Progress of the Medical Sciences. [J^^^y 

thought, tended to show that the orreat difficulty of hony union in some fractures, 
such as intracapsular fracture of the neck of the femur, fracture of the patella, 
&c., was not so much due to any other peculiarity in the structure of the parts 
engaged in those fractures as the sparing supply of blood they are furnished 
with. Mr. Williams said that Dr. Houston had examined a section of the cal- 
lus from this case with the microscope, and the detached islets of bone in the 
yellowish opalescent cartilage were quite obvious. — Dublin Medical Press, April 
17th, 1844. 

At a subsequent meeting of the society, (April 13,) Dr. Houston described 
the appearances which he had observed in a microscopic examination of a piece 
of callus from this patient. A section of this callus looked, to the naked eye, 
like a piece of cartilage — bluish, homogeneous, and compact; but when dried 
and examined with the microscope, it exhibited in every part innumerable points 
of ossification — some, isolated and distinct; others, agglomerated in heaps — the 
whole being evidently in a stage of transition from cartilage to bone. A simitar 
condition Dr. Houston presumed would have been found in his case at a certain 
parallel stage of its progress towards reparation. Here, most probably, as the 
result of the irritation of the setons in the ossifying atmosphere of the bone, 
there had been, in the first place, an effusion of plastic lymph or jelly; then a 
conversion of this material into an organized bed of cartilage; and finally, an 
accumulation of osseous matter in the cartilage, at first in the form of minute 
isolated points, but in time, in such abundance as to repair the lesion and make 
firm the bones. Acting on the presumption that about the third week was the 
period at which, if at all, the cartilaginous bed had been formed, and the pro- 
cess of laying down the bone had commenced, he had chosen that time for the 
removal of the setons; and he had withdrawn them, thread by thread, with a 
view of guarding against the extremes, either of too great irritation, or of a 
premature cessation of the reparative action, one or other of which would have 
been likely to have attended on a forcible and sudden removal of all, at Uie 
same moment. He had thought it right, too, not to leave the setons between 
the bones for a longer period than three weeks, lest a morbid rather than a sana- 
tory action might be set up by the too long-continued presence of the foreign 
bodies.— 7/;ic?., May 1, 1844. 

37. Reproduction nf Bone in Necrosis. Professor Syme exhibited to the Med. 
Chirurg. Society, Edinburgh, on the 3d of April last, some specimens to show 
that new bone was formed by the periosteum. 

In the first place he produced specimens of the imperfect reproduction which 
occurs in cases where a portion of bone is removed by mechanical violence, as 
in the operation of trepanning the skull. The loss of substance here is not com- 
pletely supplied, but only lessened, by a scanty growth of new bone round the 
margin of the aperture, diminishing in thickness from the circumference towards 
the centre, where there is usually a portion of the space occupied merely by a 
ligamentous membrane. He further illustrated this, by showing the result of 
experiments on dogs, performed in the way that Sir A. Cooper suggested, by 
removing a part of the radius, while the ulna was left entire. Here, too, the 
vacuity is very imperfectly provided with a substitute, by a conical shaped pro- 
cess of new bone from each extremity of the old one, extending from the cut 
surfaces of the breach, and tapering towards each other, so as to leave a defi- 
ciency, occupied by a ligamentous texture. He next showed a similar result 
from disease in the human subject, nearly the whole shaft of the tibia having 
died and been discharged without the formation of a successor, the appearance 
presented being precisely like that of the dog's bone just alluded to, and the 
imperfection of the limb so great as to require amputation several years after 
cicatrization of the sores. He then contrasted this preparation with one of ne- 
crosis in its ordinary form, where the old bone lies surrounded by a new shell 
ready to take its place in the event of removal. It is obvious, that this effectual 
reproduction cannot proceed from the remaining old bone, since it should in that 
case never be wanting, as there is always part of the shaft left entire, while it 



1844.] Surgery. ~ 239 

had been found, that the bone possesses in itself very limited power of repro- 
duction. The ample investing shell in question, therefore, not beinpr attributable 
to the injury of the bone that retains its vitality, must be referred, 1. To separa- 
tion and thickenino- of a lamina separated from the bone previous to its death. 
2. To the ossification of organizable substance effused from the bone previous 
to its death, 3. To ossification of the periosteum. 4. To ossification of the 
neighbouring textures, whatever they may be. The arguments in support of 
these explanations being very plausible, it has always been considered most 
desirable to ascertain the truth, by examining the process which usually takes 
place. But where patients require amputation for necrosis, or sink under it, the 
disease is almost always either so recent or so far advanced, that the source of 
ossification cannot be recognized with certainty. In the course of fifteen years' 
hospital practice, Mr. Syme has met with only three cases that afl^(^rded an op- 
portunity of dissection at the instructive period of formation, i. e., from three to 
six weeks after tlie commencement of the disease. Simple inspection of the 
preparations so obtained seems sufficient to satisfy all eyes not obscured by 
preconceived opinions, that the new bone was formed on the inner surface of the 
periosteum. The osseous substance was deposited in crusts of uniform thick- 
ness, which implied an equality of reproductive action on the surface. The 
subjacent dead bone was perfectly smooth, which it could not have been if a 
iamina, however thin, had been detached from it. The periosteum was dis- 
tinctly traced out and preserved, except at those parts where it had been de- 
stroyed by the disease; and it would have constituted i\\e cloacaB or defective 
portions of the osseous shell. In the early stao-e of the process the new bone 
was distinctly deposited in separate masses, which were plainly seen to be insu- 
lated from each other when surveyed between the eye and a light. 

Dr. Henderson differed from Mr. Syme, and expressed his belief that the peri- 
osteum performed, in the process of the regeneration of bone, whether in necro- 
sis or in fractures, only a secondary part — that it transmitted vessels into the 
organizable matter, which eventually exhibited the characters of bone, but that 
it did not possess the power of yielding directly a plastic exudation capable of 
undergoing development into cartilage and bone. He adverted to the investiga- 
tions of Miescher on the generation of callus, as proving that it was yielded by 
the old bone only, and observed that the whole scope of the evidence afforded. 
by the anatomy and physiology of bone and periosteum, tended to establish the 
doctrine, that the periosteum, though necessary indirectly to the growth and 
nutrition of bone, by affording it a supply of arterial twigs, is incapable of gene- 
rating bone immediately from its own surface. Satisfied that such was the con- 
clusion to which the formation of callus, and the generation and growth of bone, 
in the ordinary process of development, unequivocally pointed, he felt great 
difficult}^ in admitting that the specimens exhibited by Mr. Syme were calcu- 
lated to show that the periosteum had an office conferred upon it, in the case of 
necrosis, which it possessed in no other circumstances. He conceived, that 
there was nothing in these specimens irreconcileable with the views he held on 
the functions of the periosteum; and he called attention to the circumstances, 
that where the new bone, in the specimens, was the thickest, it had an imme- 
diate connection with the old — that where detached scales of bone adhered to 
the periosteum alone, the dead bone over which they lay was in several places 
rough, intimating that a thin layer had been detached from it, and that where 
the scales which adhered to the periosteum corresponded to a smooth surface on 
the dead bone, it was extremely probable that they had originated from plastic 
matter, which had been thrown out by the inflamed bone, before the occurrence 
of necrosis. Bone, on becoming inflamed, did not die instantly, and the analogy 
of all other tissues in the state of inflammation seemed to render it certain that 
an organizable exudation may take place from the surface of an inflamed bone. 
These considerations induced Dr. Henderson to deny that the specimens brought 
before the society by Mr. Syme proved, or even rendered it probable, in the 
face of all the reasons that could be given for limiting the agency of the perios- 
teum in the growth and reproductions of bone to the secondary rank, which he 



240 Progress of the Medical Sciences, [^^^V 

had alluded to at the outset, that the periosteum could ever be the source of the 
new bone which is generated in necrosis. 

Professor Miller stated, that he differed but slio^htly from Mr. Syme, as to 
the reproduction of bone in necrosis. His creed was very simple. In in- 
ternal necrosis, of course, the work of reproduction is entirely effected by the 
surrounding bone. In external necrosis, he considered that the new forma- 
tion of bone was of iwo parts, an internal and external, separated from each 
other by the sequestrum or dead portion in the first instance; but on the sepa- 
ration of this, coalescinof and becominpr consolidated to form an efficient sub- 
stitute for the part destroyed. He believed that, in most cases, the doomed 
bone died very speedily, at least in its external surface, as indicated by its 
smooth unchanged appearance, — seeming as if a portion removed artificially 
from the skeleton. That at its circumference, the living bone speedily became 
universally vascular, and underwent the true inflammatory process; thereby 
establishing a sulcus of separation, by ulceration, precisely analogous to what 
takes place in detachment of a slough in the soft parts. That as this sulcus 
deepened, separation followed close upon ulceration; the depth being as yet 
altogether inconsiderable, when osseous nodules have begun to make their ap- 
pearance on and around the living margin. This reparative eflfort on the surface 
of the old bone, almost coeval in its origin with that of the process of separa- 
ralion, he considered to be the starling point of the new structure, vt'hich thence 
proceeded in two layers; the deep^ by what may be termed osseous granulation, 
following hard on the heel of ulceration in the separative sulcus, forming a con- 
tinuous mass which occupies the place of what has been destroyed by the ulce- 
ration, and which, shooting upwards, assists in the extrusion of the dead part 
which the ulceration has fairly detached. At the same time a sw/?er^aa/ layer, 
from the same origin, extends beneath the periosteum, and in close cohesion 
with it. apparently formed by that membrane; investing the dead portion on its 
external aspect, in a more or less continuous sheath of cortical formation — im- 
perfect at certain points, where cloacae are said to exist. 

As to the formation of these cloacae, he quite acjrepd with Mr. Syme, that 
they depended on deficiency of the periosteum. First, we have ostitis, then 
suppuration, and thereafter the full establishment of the necrosis. The matter 
collects in greater or less quantity beneath the periosteum, and sooner or later it 
must be discharged through that membrane, into the soft parts, and thence ex- 
ternally. If an incision be made, as it should be, that aperture in the mem- 
brane is permanent; for the acutely infiamed part does not heal, on the contrary, 
the chasm widens by ulceration. If incision be withheld, the perforation is 
by ulceration; the loss of substance is more extensive, and consequently more 
surely permanent. The advancing sheath of cortical bone coming to such aa 
opening is interrupted, and there an aperture in it, termed cloaca, results, pro- 
portioned in form and extent to the deficiency of the membrane; for though 
other surrounding textures, as cellular or muscular, seem to have the power of 
assuming both the periosteal appearance and function, it is only when they are 
non-inflamed and capable of emplaslic exudation; which in this case they are 
not, but, on the contrary, inflamed and suppuraiing, forming part of the canal 
through which the general purulent secretion is being discharged. In the for- 
mation of provisional callus, after simple fracture, he believed that ossification 
of the plasma was begun by the parent bone, taken up by the periosteum, and 
continued by the adjacent soft parts at the central or other pnrls of the peri- 
phery, where that membrane might happen to be deficient; and that these other 
adjacent textures were capable of the assumption of that function, because they 
were undergoing a arade of the inflammatory process short of suppuration, and 
favourable to the effusion and nulriiion of an efficient plasma. 

In death of the entire thickness of a bone, he believed that reproduction took 
place in a similar manner. That the deep portion shot forth from the truncated 
extremities of the old bone, assisting by its growtli to dislodge the sequestrum; 
that the external or cortical layer was begun by the old bone, but mainly con- 
structed by the periosteum; that, as usual, on extrusion of the dead portion, 



1844.] . Surgery. 2,41 

the two new formations coalesced to form the substitute; and that when the 
death had proved so extensive as to render complete development of what might 
be termed the heart or pith of the new formation impossible, reproduction did 
not occur satisfactorily, if at all, — the cortical portion, when alone and unsup- 
ported, being unequal to this end. 

Consequently, he believed, that in the reproduction of bone, in genera], three 
textures might be employed. Bone formed bone better and more readily than 
did any other texture; periosteum was second only to bone, and superior to all 
other textures in this respect; other soft parts contiguous to periosteum, might 
supply that membrane's deficiency by assuming both its appearance and func- 
tion, but only when these other soft parts were themselves not truly inflamed. 

This creed he found applicable to all the surgical examples of osseous formation 
— as in ulcer of bone, fracture, necrosis, change on end of bone after amputation, 
&c. and capable of satisfactorily explaining all the phenomena attendant thereon. 

Mr. Syme had adduced the reparation of deficiency in the cranium as a fact 
in favour of his argument, that periosteum is the main agent in reproducing 
bone. Professor Miller thought it had a precisely opposite bearing. The repa- 
ration was at first membranous : but after many years the aperture became 
closed by shelving bone gradually extending from the margins of the old, and 
evidently the product of that texture alone. Now, frequently, in the operation 
of trephining, the periosteum was not destroyed, but simply elevated with the 
rest of the flaps, and afterwards reopened ; it was there consequently to secrete 
bone, if it chose; and, at all events, the dura mater was probably undisturbed, 
at least an equally efficient and quite analogous membrane ; a belter membrane, 
in fact; for a portion of the calvarium deprived of its periosteum by even rude 
violence, does not necessarily exfoliate, whereas a detachment of the dura mater 
is almost uniformly followed by necrosis of the corresponding portion of bone. 
Yet in the repair of a solution of continuity in the calvarium, we seldom if ever 
find the formation of .cortical substitute; all osseous reproduction, in this in- 
stance, is from the parent bone alone ; neither periosteum nor dura mater partak- 
ing in the eff'ort. 

Professor Miller also directed the attention of the Society to the osteophyte 
formations, found in the calvaria of women who have died recently after par- 
turition — quoting from a review of M. Ducrest's paper on that subject, in the 
March number of Dr. Cormack's Journal. The prominent characteristic of this 
affection was that the new osseous formation was intimately incorporated with 
the internal surface of the skull, and could scarcely be separated from it, while 
the dura n»ater was non-adherent, and but little changed from its normal appear- 
ance, — a fact which also told against the idea of the periosteum possessing a 
superior power of osseous formation. 

He begged to repeat, that he believed the periosteum had the power of form- 
ing new bone, in an eminent degree; but that in this respect it was altogether 
secondary to the parent bone. That practically, it mattered not whether the 
periosteum eff"used the plasma, as well as superintended its organization and 
transition into bone, as maintained by Professor Syme; or whether it only nou- 
rished a plasma wliich had been furnished to it by the old bone previous to its 
death, as maintained by Professor Henderson. And he trusted the society 
would remember that however the disputants might difl^er in the minor details, 
yet on the important and practical point they were all agreed; namely, that the 
presence of periosteum is essential to the formation of the cortical substitute; 
and that, consequently, in the treatment of necrosis, we ought to have our atten- 
tion much directed towards ensuring the integrity of this membrane, by early 
evacuation of pus, and other means calculated to subdue and limit intense and 
destructive inflammatory action. 

Dr. Bennett remarked, that so long as pathologists adopted an exclusive view 
regarding the production of bone from any particular tissue, so long would there 
be continual dispute. Selected preparations might be brought forward to sup- 
port any theory advanced. Modern researches had demonstrated that new bone 
following fracture or necrosis was formed exactly in the same manner as bone 
No. XV.— July, 1844. 21 



242 Progress of the Medical Sciences, [Ju^y 

originally produced in the foetus. Blood plasma was poured out in the neigh- 
bourhood of the injury, which was first transformed into cartilage, and then into 
bone. The essential part of the process was the exudation of healthy blood 
plasma, capable of being converted into osseous structure; the particular tissue 
or vessels which furnished it was a matter of secondary importance. The exu- 
dation might be furnished in one case from bone, in another from periosteum, or 
the surrounding tissues, and in a third, from all of them. Dr. B. considered 
that each of the views which had been contended for was true to a certain ex- 
tent, but incorrect, in as far as they were exclusive in their nature. — Lond. and 
Edin. Monthly Journ. Med. Set., May, 1844. 

38. Necrosis. Dr. J. A. Lawrie relates in the London and Edinburgh 
Monthly Journal of Medical Science, (August 1843,) four cases of necrosis from 
which he deduces the following practical and physiological inferences. 

"In the treatment of extensive necrosis, two practical difficulties present 
themselves;— first, in supporting the constitution, and preventing hectic ; and, 
second, in the very tedious process of production of new bone, and the ultimate 
cure, by discharge of the dead portion. The latter is known to consist in the 
deposit of new bone, around the old and dead bone, encasing it, and subjecting 
it to the very doubtful process of absorption, or of separation and escape through 
the cloacae in the new bone, and the ulcers in the soft parts. This process is so 
tedious as sometimes to occupy a lifetime, or to subject the patient to the very 
painful and uncertain operation of removing the dead bone, or even amputating 
the limb. So far as I know, no efficient means of meeting and overcoming these 
difficulties have yet been proposed. The two cases which I have related, show 
that in certain cases, and these the most severe, they may be obviated by the 
early removal of the dead bone, before it is encased or entangled in new bone. 
In neither of the cases was any incision required; in the first, on account of the 
extensive exposure of the bone; and, in the second, from- its being broken, and 
its extremity projecting through an opening in the soft parts. We cannot, how- 
ever, expect to find all our cases so favourably circumstanced. In some, the 
first steps will consist in exposure of the dead bone, by extensive incisions; and 
the second, in removing the dead bone by the saw and forceps. I have, at pre- 
sent, a case of necrosis of the tibia, under treatment, in which these steps will 
require to be put in practice.* The advantages of the operation are too nume- 
rous and obvious to require to be detailed. 

"The physiological inferences which may be drawn from these cases, to my 
mind decide the question, as to the source from which bones are repaired, or 
regenerated after necrosis. The opinions on this subject were long divided 
between the periosteum and soft parts on the one hand, and the bone on the 
other. That bone, or at all events, calcareous matter, may be deposited in 
almost any organ or membrane of the body, is too well ascertained to make it 
improbable, that the same substance may be formed by the soft parts in the 
neighbourhood of bone, or by the periosteum, whose peculiar functions are to 
envelope and invigorate bone. That periosteum can form bone I well know, 
having seen bone deposited on both its surfaces, and into its substance, in con- 
siderable quantity. But it is one thing to admit that the vessels of periosteum 
may secrete or deposit spicula?. of bone, and another, to subscribe to the doctrine 
that this membrane is the efficient agent in the production of the mass of ossific 
matter, necessary for the reunion of broken bones, or the reproduction of an 
entire bone with the exception of the epiphysis. Both of these processes I have 
long been convinced are performed by bone, and can only be eflfected through its 
agency. It is not my intention to speak of the union of fractures, — that subject 
not being at present under consideration. I shall therefore limit myself to the 
second, — reproduction of new bone after necrosis; and in the first place, it is 
worthy of remark, that those bones which have epiphyses are much more cer- 
tainly and rapidly regenerated after necrosis, than the flat bones, and those 

* Since this paper was written, the case has been operated on, and with complete 

success. 



I 



1844.] Surgery, 243 

which have-flo epiphysis. If a lar^e portion of a cranial bone die and separate, 
it is frequently never restored; if it be renewed, it is by membrane in the first 
instance, and ultimately by the very slow transformation of that membrane into 
a thin plate of bone. I am not aware that the bones of the face, excepting of 
course the lower jaw, are ever restored. On the other hand, the facility with 
which the cylindrical bones pour out osseous matter is well known. In the 
next place, if the epiphyses be removed with the body of the bone, no new bone 
will be formed. This is most frequently illustrated, in the lower jaw, and pha- 
langes of the fingers. In the remarkable case published by Mr. Perry, {Med. 
Chir. Trans, xxi. p. 90,) of necrosis of the lower jaw, while the epiphyses pre- 
served their vitality, a powerful effort was made to restore the dead part; but 
after the epiphyses died, the new bone died also, — the whole came away, and 
no further attempt to renew the bone appeared. Lastly, in the cases above re- 
lated, and I believe that attentive observation will confirm the remark in all 
similar instances, the new bone was formed by the epiphyses. Where the old 
bone is extensively exposed, osseous matter is poured out by both epiphyses 
behind the dead bone, or behind that plane of the bone which is least exposed, 
and farthest from the surface; the new bone appears in the form of shoots or 
processes, which advance from both epiphyses, until they meet and coalesce. 
The deposition is continued from behind forward, until the integrity of the new 
bone is restored, and the old bone enveloped in it. It is in this way, and not 
by the deposit of bone on the surface of the periosteum, that the old bone is 
encased in new. 

** A question, at once of physiological and practical importance, here suggests 
itself. What part does the dead bone play in this process] Does it act as a 
stimulant to the deposit of ossific matter? Does it serve as a mould for the new 
bone? If it were removed, would the process be arrested? In all of these 
questions I would reply in the negative. I do not think that the presence of 
dead bone is more required to assist in any of the processes involved in the 
above queries, than the presence of a slough of the softer parts in the generation 
of new flexible tissues. When the entire thickness of a cylindrical Ijone dies, 
the first step towards regeneration consists in an attempt to get rid of the dead 
part, by the absorbents forming a groove round the dead portion, gradually cut- 
ling it through, and isolating it from the living. The next step, to a certain 
extent cotemporaneous with the first, is the deposit of new osseous matter all 
around this groove, springing from the bone; the last is the surrounding of the 
old bone with new% in the manner already explained. The new bone begins to 
form before the old has separated, and continues after the connection between 
the two has been quite dissolved. Currie's case appears to me to entitle us to 
answer the second and third queries in the negative; the old bone was removed 
long before the new was deposited ; the process so far from being thereby ar- 
rested, was greatly accelerated, and the form of the new bone was much more 
symmetrical than if it had been slowly deposited around the old as a mould. 
It may be asked, if this view of the matter be correct, why is it not thrown off 
as is a slough of cellular tissue? I believe that the impediments to its escape 
are mechanical, and not physiological ; the soft parts which cover it, the irregu- 
lar line in which it dies, and the vitality of the cancellous structure next to the 
epiphysis, extending for some distance within the dead outer case, render its 
escape impossible, long after its presence has become a source of retarding, it 
may be, of fatal irritation. 

"How soon may the dead bone be removed by operation? The answer ap- 
pears to be: — As soon as the inflammatory stage has passed, suppuration been 
fairly established, and the constitutional symptoms will permit. The nature of 
the operation to be performed must depend on the extent of the disease. When 
the entire thickness is involved, the necrosed part should be exposed, and a por- 
tion cut out, as in Currie's case, and occasional attempts made to extract the 
portions connected with the epiphyses. There is little risk in hurrying them 
away too soon, provided violence is not used in the attempts; they will become 
loose when the natural process of separation is complete, and then compara- 



244 Progress of the Medical Sciences, U^^Y 

tively little force will be required for their extraction. When the surface of a 
bone only is exposed and necrosed, it seldonn happens that the dead part is en- 
cased in a new bone. It generally scales off, and finds its way through the 
ulcer in the soft part, or through an abscess. Should the dead portion be exten- 
sive, and the position of the bone admit of it, it would save time to lay open the 
sinuses, expose the bone, and remove with a sharp chisel all the dead portion. 

39. Expediency of operating in Cancerous Jlffections. — In our preceding Num- 
ber, (p. 454), we gave a brief notice of a memoir on this subject, read to the 
Royal Academy of Sciences by M. Lerov d'Etioles, and we now add some 
further details. 

The most important point in this surgical question is to determine if the dis- 
ease is, in the first instance, purely local, and finally degenerates into a constitu- 
tional malady, and if an early operation prevents this degeneration. This belief, 
though generally acted on, is far from being borne out by statistics. Thus, M. 
Leroy states that in 801 operations, 117 were performed within less than a year 
after the first appearance of the disease, and that of these 117 cases 61 had 
relapsed when the documents relating to them were supplied to him. 

The results of operations for cancer of the lip are curious because of the dif- 
ference that exists between the two sexes. Thus, in 633 males, there were 165 
cases of cancer of the lip, 1 14 of which were operated on by excision, and 12 by 
caustic; the relapses were 15, that is to say, about one-eighth. Among 2148 
females affected with cancer, 34 had cancer of the lip, 22 were operated on, and 
7 relapsed, that is to say, a third. 

This difference in the relapses depends on the difference in the cause and 
nature of the malady. In the male, cancroid tumours produced by an external 
cause tend to diminish ; in the female they degenerate into true cancer. In the 
cancer of the tongue, there is not the same difference in the result — the termina- 
tion is equally fatal in both sexes. In 9 operations on cancer of the tongue, 3 
were performed in less than a year from the commencement of the disease ; the 
6 other patients died from relapse of the disease. 

The following are the results of operations on tumours of the breast: — 

Of 277 operations, 73 have been performed within the last two years, and the 
result is not yet known ; 204 cases remain, and in 24 deaths occurred, in one 
case soon after the operation, and 87 others have already relapsed, so that more 
than one-half of the operations have failed ; 27 were operated on in less than one 
year from the first symptoms of the affection. 

M. Leroy finally maintained the following conclusions : — 

1. Extirpation does not arrest the progress of cancer. 

2. Extirpation should not be adopted as a general method, except in cancer of 
the lip and of the skin. 

3. Cancer of other organs should not be extirpated, except when hemorrhage 
from ulcerated cancer threatens speedy death. M. Leroy's memoir was founded 
on the results of the practice of 70 surgeons, who communicated to him the par- 
ticulars of all the cases of cancer they had operated on. — Dublin Med, Fress, 
May 1844. 

40. Description of a peculiar form of Ulceration to which Cicatrices are liable. — 
Mr. Robert Smith communicated to the Surgical Society of Ireland, (April 
13th, 1844,) a description of a peculiar form of ulceration to which cicatrices are 
liable, and which he terms the "fibrous ulcer." Mr. Smith does not consider 
it as a malignant disease, though he says that in a majority of cases, it is only 
curable by free excision. 

"This peculiar ulcer generally makes its appearance only in a cicatrix; nor 
does the nature of the lesion of the skin, of which the cicatrix is the result, 
eeem to exercise much influence upon the occurrence of the subsequent morbid 
change, for it is established with equal frequency in the cicatrices of lacerated 
wounds, scalds, or burns. I have never seen it attack the cicatrix of a simple 
incised wound. It does not appear until the cicatrices have existed for several 



1844.] Surgery, 245 

years, and its progress, when once formed, is singularly slow. It frequently 
happens that the cicatrix resulting- from the orijrinal injury is attacked by ulce- 
ration, heals and again ulcerates, the ulcer presenting no remarkable or peculiar 
character. This may occur repeatedly between the period of the receipt of the 
injury and the establishment of the ulcer under consideration; but when this is 
once formed, there is an end to every process of reparation ; but so slow is this 
ulcer in enlarging, that a long period may elapse before the patient's attention 
is sufficiently attracted to it to induce him to seek for professional advice. 
Gradually and surely, however, the disease spreads, and the ulcer increases, not 
only extending by its circumference, but also becoming deeper, and engaging 
in their turn all the subjacent structures, until at length the periosteum (if the 
disease be situated over a bone), becomes implicated, and ultimately the bone is 
absorbed and the fracture is the result. The disease, no matter how long it 
may have existed, does not contaminate the lymphatic glands. They may be- 
come sympathetically enlarged, but do not present those characters which dis- 
tinguish them when they are the seat of scirrhous disease. The formation of 
the fibrous ulcer is usually preceded by the appearance in some part of the cica- 
trix of a small, insular, hard tumour or wart-like excrescence, the surface of 
which is smooth, and covered by the layer of cuticle which invests the whole 
surface of the cicatrix. This tumour remains for a variable period of time free 
from ulceration and devoid of pain. Several such tumours may form before the 
process of ulceration begins, though the reverse happens in the majority of cases, 
and indeed, in some examples of the disease, the ulcer is not preceded by any 
such tumour, but the cicatrix here and there presents spots of ulceration, which 
gradually coalesce, and secrete a thin, unhealthy matter. By slow degrees, the 
ulcer enlarges and ultimately spreads beyond the limits of the original cicatrix; 
its surface presents a very unhealthy aspect, being in some cases covered wiih 
a number of hard circular tumours, resembling the granulations of cancerous 
ulcer; while, in other examples of the disease, nothing like granulation is seen, 
but in their place a number of villosities of fibres of a white colour, a dense, but 
at the same time, brittle texture, placed close to and parallel with each other, 
while at the same time they are perpendicular to or at right angles viith the 
surface of the surrounding integument; this singular arrangement characterizes 
the ulcer, and also exists when the latter presents a granulated surface ; for the 
granulations upon close examination, are found composed of a collection of thin 
parallel fibres which are perpendicular to the surface from which they spring. 
With the point of a needle they can be easily separated from each other, and 
very often even the end of a small probe can be passed between them down lo 
the bottom of the ulcer. It is from this anatomical character that I have ven- 
tured to apply to the disease the name of' Fibrous Ulcer.' 

"The discharge is thin, purulent, offensive, and occasionally streaked with 
blood; the pain, at first but slight, becomes more severe and constant, and a 
certain amount of hectic fever shows itself as the disease advances. The integu- 
ment surrounding the ulcer is usually diseased to a greater or less extent, being 
frequently studded with small wart-like tumours; it is thickened, divided by 
furrows or fissures, more or less deep. By degrees the ulcer spreads over the 
whole of this diseased integument, and a fresh portion of the skin then becomes 
the seat of the same morbid process, presenting the same fissured appearance, 
as it were preparing the way for the spreading of the ulcer which may then 
attain a very considerable size. From what has been said, it appears that the 
ulcer may present either a granular and tuberculated or a fibrous surface. In 
the former case, however, the peculiar arrangement of the fibres which I have 
described can still be demonstrated ; the granulations are large, round, firm, and 
bleed freely; the interval between them are dross, present a foul, yellowish or 
greenish aspect; the edges are irregular, and the discharge offensive. In all the 
cases which 1 have seen the surface presented a number of white dots, which, 
upon close examination, were found to be the extremities of the fibres, com- 
posing the granulation. Sloughing frequently attacks and destroys the entire 
surface, and when this process has ceased, the ulcer again presents its former 

21* 



246 Progress of the Medical Sciences. [July 

tuberculated surface. This form of the disease closely resembles the ulcer of 
carcinoma. When the ulcer from the beginning has a distinctly fibrous surface, 
destitute of granulation, this sloughing process does not usually take place, but 
the discharge is still foetid and profuse. In both cases the patient is destroyed 
by hectic fever, and in both, the state of the surrounding integument is similar, 
the same fissures are seen, with here and there a few small wart-like ele- 
vations." 

" The disease resembles the ulcer of the eyelids described by Dr. Jacob, in not 
contaminating the lymphatic glands, in destroying every structure with which 
it comes in contact, and in the intractability of its nature, but it differs from the 
ulcer of the eyelid in the fibrous arrangement to which 1 have alluded ; neither 
of the ulcers are malignant, in the full and proper meaning of the word. I have 
have never seen the fibrous ulcer cured or even much benefited by local appli- 
cations. Excision seems to be the only mode of treatment to be relied upon ; it 
is therefore a matter of the greatest importance to be able to recognize the dis- 
ease in its commencement, and before it attains such a size as to render excision 
impossible." — Dublin Med. Press, May 1844. 

41 . Comminuted fracture of the base of the Cranium produced by a fall on the feet. 
By M. Robert. A carrier, about forty years of age, fell from a height of about 
thirty-five feet, on the •24th of May, and lighted on his feet. He was slightly 
stunned, but did not appear to be otherwise hurt, and walked home, and was 
able next day to return to his occupation. Four days after, he began to com- 
plain of acute pain in the right ear, and passed a sleepless night. Three weeks 
after, acute headache came on, and his right eye was observed to squint inwards. 
He then entered the hospital of La Pitie, where they endeavoured to relieve his 
headaches by means of bleeding, blistering, and morphia, but without affording 
him any relief. He then went to the hospital Beaujon, and came under the care 
of M. Robert. No paralysis of motion or sensation was observed in any part of 
the body. Fixed pain in the head, and darting pains in various parts of the body 
were alone complained of. 

On the 20th of September, or four months after the accident, he was suddenly 
seized with violent delirium, and in spite of active depletion, died in twenty-four 
hours. 

On dissection, the two clinoid processes of the sphenoid bone were found 
separated from each other, and from the square plate; the petrous portion of the 
temporal bone was fractured transversely through its upper third, and a large 
scale detached from the bone. Though the brain was examined with care, it 
presented no morbid appearances. The arachnoid membrane opposite the frac- 
tured portions of bone, and over the central portion of the posterior lobes of the 
brain, was slightly opaque. The eighth pair of nerves was found torn across. 

M. Robert remarks, that this is one of the most interesting cases of fractured 
base of the cranium on record, seeing that no symptoms followed the fall which 
could lead to the suspicion of such a severe accident, and seeing that the fatal 
symptoms did not come on till four months after the injury. Dissection alone 
showed the probable cause of the squinting — viz., from the rupture of the eighth 
pair of nerves. — Ed. Med. and Surg. Journ., Ap. 1844, from P Experience, 28th 
Sept. 1843. 

42. Polypous tumour of the Bladder removed by lithontriptic instruments. By 
M. Vache. a man addicted to strong drinks became affected with all the symp- 
toms of stone in the bladder, constant desire to micturate, pain in passing water, 
which was occasionally suddenly stopped, and was frequently mixed with blood, 
&c. On being sounded carefully several times, a soft tumour was detected pro- 
jecting from the right side of the trigonal space of the bladder. By careful ma- 
nipulation it was ascertained that this tumour was connected with the bladder 
by a narrow neck, and, by using lithotritic instruments, it was seized and partly 
destroyed. The patient was put in a bath, and there passed some fragments of 
the polypus and a little blood. The next day more of the polypus was passed. 



1844.] Surgery. 247 

No fever or hemorrhage ensued ; and five days afterwards, the remainder of the 
tumour vi^as broken down, and many large pieces came away with the urine. 
The pieces had the exact character of nasal polypus. No fever or hemorrhage 
followed the operation ; only the first urine passed after the operation contained 
a little blood. Eight days after, the instruments were again introduced, but no 
remains of the tumour could be discovered in the old site ; but a small fung-ous 
projection with a broad base was felt on the left side of the trigonal space. The 
projecting portion of this was removed in the same way. The patient, from this 
period, got rid of all his uneasy sensations ; his urine was retained for a longer 
period ; and, six weeks after the first operation, he was dismissed cured. The 
most careful examination failed to detect the slightest remains of the fungous 
tumour. — Ibid, from Ibid., 5th Oct. 1843. 

43. Foreign bodies in the external Auditory Canal. — M. Marchal related to the 
French Academy of Medicine the following case : — 

A captain in a cavalry regiment, began to be rather deaf of the right ear, in 
the year 1821. One day, during the winter of that year, he perceived a kind of 
motion in the ear ; it seemed to him as if something had given way, and for a 
short time he heard much belter. From that date he remained subject to occa- 
sional deafness, and to humming in the right ear. At the beginning of the pre- 
sent winter he was seized with violent and continued headache, with buzzing, 
and nearly complete deafness on the right side. As these symptoms were attri- 
buted by me to a certain degree of cerebral congestion, I bled him from the arm, 
and applied fifteen leeches over the right ear. The headache was calmed, but 
the humming continued. I then examined the ear carefully; this I had some 
trouble in effecting, from a certain degree of flattening and thickening of the 
canal. Nothing was discovered, but thinking that there might be some hardened 
cerumen deeply situated, I ordered injections with an emollient fluid. These 
injections were continued, until one day, to the great surprise of the patient, a 
rosary-bead escaped. From the alteration which it had undergone, it is evident 
that it must have remained a great length of time in the ear. M. Smidt does 
not remember when it was introduced, but thinks it must have been when he 
was only four or five years old, in which case it would have remained forty-five 
years in the ear. The bead being perforated, M. Smidt, rationally enough, con- 
jectures that the different positions it assumed explain the alternations of surdity 
and tolerable audition which had so long been observed. From the moment of 
the extraction of the foreign body, he ceased to suffer from headache, and the 
audition became as perfect on the right as on the left side. 

"Cases such as the above," said M. Marchal, "in which foreign bodies in 
the ear have remained long unrecognized, are not rare in the annals of science. 
Among these are two worth recalling to memory. Power was treating a young 
girl affected with abundant salivation, who had fallen into a state of marasmus, 
and seemed nearly expiring. He had tried, without success, every means of 
treatment that he could think of, when he was induced, by some reason or other, 
to examine the auditory canal. From this he extracted a piece of fetid wool, of 
the presence of which the young girl was totally unconscious, and she very soon 
recovered her health. The second case is given by Fabricius, of Hilden. A 
little girl allowed a small ball of glass to get into the meatus auditorius. Vain 
attempts were made to extract it, and it was lost sight of. Some time afterwards 
hermicrania on that side made its appearance, as also incomplete paralysis of the 
corresponding side of the body, accompanied by pains similar to those of the 
head, and, like them, subject to changes under the influence of atmospheric 
variations. After suffering five years she was seized with epileptic fits, and the 
left arm became atrophied. Fabricius learnt, by chance, from his patient, the 
circumstance of the glass ball having been introduced years before into the ear. 
On examination he ascertained that it was still there, extracted it, and the acci- 
dents ceased. In this case the whole train of symptoms appear to have been 
produced by pressure on some branches of the fifth pair." 

Baron Larrey, during the inspection of Algeria, which he made a short time 



248 Progress of the Medical Sciences, [Ju^y 

before his death, used to recommend to the soldiers to cover their ears well when 
they slept in the field, in order to prevent the penetration of insects, or the deposit 
of their larvae. On one occasion a man affected with incurable otorrhcea was pre- 
sented to him. He examined the ear, took hold of a pair of forceps, and drew 
out a white worm, two-thirds of an inch in length. The otorrhcea was, as may 
be supposed, soon cured. 

M. 13egnin remarked, that in the army of Africa such cases were not rare. He 
had seen several instances in which insects had thus deposited larvae in the ears 
of soldiers, who had subsequently presented very anomalous symptoms. — Lancet, 
March 16, 1844. 

44. Fractured Pelvis, with laceration of the Bladder. — By M. Hall, Esq. A 
stout man was run over by a heavily laden wagon. When seen by Mr. Hall, 
half an hour after the accident, the patient was in a state of extreme collapse, 
with a pulse scarcely perceptible ; on the slightest motion he complained of 
much pain in the back, and thought the wheel had passed transversely over the 
loins. He was perfectly conscious, and answered questions intelligibly. There 
had been some haemorrhage from the penis. There was slight distension of the 
hypogastrium, which was more manifest in the right iliac region. The right 
ilium was very movable, and crepitus could be distinctly felt extending back- 
wards towards the sacrum. External warmth, and internal stimuli, were imme- 
diately had recourse to, and after the lapse of a short time symptoms of reaction 
appeared. 

Nine hours afterwards, when again seen, the pulse had risen ; no urine having 
been passed since the accident, a catheter was introduced, but no urine could be 
obtained. Some hours afterwards the catheter was again introduced, but with 
the same unsuccessful result. Extravasation of urine evidently was taking 
place; several deep incisions were made in the distended parts, and an exuda- 
tion of urine followed. The next day collapse again came on, and the patient 
died forty-five hours after the accident. 

Autopsy. — The scrotum distended, with lividity there and the right iliac re- 
gion; the upper part of both thighs much distended with fluid. The caecum and 
right ascending colon excessively tympanitic, and full of black patches from 
effused blood. The symphysis pubis completely separated to the extent of at 
least one inch and a half in the upper portion. On dissecting back the bladder, 
it was found that the right fractured end of the pubis, which projected inwardly, 
had entered (below the reflection of the peritoneum) that 2;iscws, producing a per- 
foration of its tunics to the extent of two inches or more ; another laceration ex- 
isted, less in extent, but more posteriorly towards the right side. Several loose 
fragments of bone were quite detached in the pelvis; two or three were in the 
cavity of the bladder, which was much contracted. The right ilium was fractured 
through its whole length, and the division of bone appeared to extend through 
the sacrum. A complete separation of the fractured portion of the ilium had 
taken place. The pubis was also fractured obliquely through the right foramen 
ovale, and from this part had several rough projections pointing inwardly; these 
most probably were the cause of the inferior rent. — Frov. Med. and Surg. Journ, 
May 1, 1844. 

45. Cure of Nsevi Materni hy inoculating with Croton Oil. — M. Lafargue re- 
commends the following method of curing nasvi materni. Five or six punctures 
to be made on and among the naevus, with a lancet dipped in croton oil, just as 
in vaccination. 

Each of these punctures, he says, causes immediately a pimple, which, in 
thirty-six hours, is developed into a little boil. These boils unite, and form a 
red-hot painful tumour, covered with white crusts, and resembling a small car- 
buncle. Two days afterwards tlse scabs separate, and in lieu of the najvus is 
seen an ulcer, which is to be treated on general principles. It w^ould be danger- 
ous to make more than six punctures on a very young infant, as the irritation 
and fever are considerable. — Frov. Med. Jour.., Feb. 17, 1844. 



1 844, J Surgery. 249 

46. Extirpation nf the Astragalus. — M. Rognetta read to the Ro5'al Academy 
of Sciences, Feb. 13th, a niemoir, written, conjointly with M Fonrnier De- 
schamps, on this subject. The followino- are the conclusions of the memoir : — 

1. The power which luxates the astragalus usually acts through the medium 
of the tibia, and converts that bone into a lever of the first order. 

2. Luxation of the astragalus usually occurs in young and vigorous persons; 
in fact, it presupposes great resistance in the luxating lever, (the tibia.) In old 
persons, the bones are fragile and easily broken, consequently the tibia generally 
breaks, and the force being then expended on the bones, the leg can scarcely 
lacerate the skin and displace the astragalus. 

3. The astragalus is more easily dislocated when the forepart of the foot is 
fixed by some invincible obstacle ; the weight of the body then acts by commu- 
nicating an impulse to the tibia, which is converted into a lever of the first order; 
the fulcrum of the lever being the calcaneum, the power being applied at the 
knee, and the resistance being at the ankle. The leg and the foot are recipro- 
cally extended. The external malleolus is usually first fractured, and then the 
mortise of the tibia acts powerfully on the astragalus. 

4. When dislocation of the astragalus is complicated with a penetrating wound 
of the joint, the wound is usually consecutive to the luxation, and is caused by 
the continued action of the lever. 

5. When dislocation of the astragalus is complicated with fracture of the mal- 
leoli, such fracture usually precedes and favours the occurrence of the disloca- 
tion ; fracture of the shaft of the tibia is, on the contrary, consecutive to the 
dislocation, and is caused by the fall of the body. 

6. Luxation of the astragalus, accompanied with rotation of that bone on its 
axis, supposes that the integuments of the dorsum of the foot are not ruptured. 
If a wound exists it must be consecutive. 

7. The astragalus is seldom fractured at the same time that it is dislocated. 
When it is so fractured, the complication always precedes the luxation and sup- 
poses the intervention of a much greater violence than when the bone has been 
luxated without being fractured. The broken part of the astragalus always cor- 
responds to its pulley, and should always be regarded as a foreign body and 
removed. 

8. In order that luxation of the astragalus may occur, it is necessary that 
the foot and the leg should be so extended on each other that the tibia becomes 
almost parallel to the bones of the tarsus. 

9. Extirpation of the astragalus has been frequently performed, and almost 
always with success, and the bad symptoms, existing previous to that operation, 
have subsided soon afier its performance. This result, as it shows that the ope- 
ration acts as if by removing strangulation, leads to the precept that the pulley 
of the astragalus should always be removed entirely. The scaphoid process of 
the astragalus naay, on the contrary, be left in situ if it has been broken off and 
retains its ligaments and natural relations. 

10. When serious symptoms supervene after extirpation of the astragalus, 
they should be regarded as unconnected with the operation, being, in fact, caused 
by the primary injury sustained by the parts, or by injudicious attempts at reduc- 
tion previous to the extirpation of the bone. 

11. The circumstances requiring amputation are independent of the luxation 
of the astragalus and the penetrating wound of the ankle-joint ; they are exten- 
sive destruction of the soft parts, crushing of the bones of the leg, &c. 

12. Extirpation of the astragalus does not always cause either anchylosis of 
the ankle-joint or shortening of the foot, as is commonly thought; if the mal- 
leoli are not fractured, we may hope for recovery with anchylosis or much 
limping.— i^ui. Med. Press, Ap. 24, 1843. 

47. Treatment of obstinate Strictures of the Urethra. — Prof. Svme, in a paper 
read before the Medico-Chirurgical Society of Edinburgh on the treatment of 
stricture of the urethra in cases where the ordinary means prove inefficient, en- 
deavoured to show that in such instances, an attempt to eflTect dilatation by bou- 



250 Progress of the Medical Sciences. [July 

gies was no less dangerous than useless. Division of the stricture either by 
subcutaneous puncture when it is seated in the pendulous part of the canal, or 
by free incision upon a grooved director when it lies behind the scrotum, was 
recommended, as having proved completely successful incases that had resisted 
every form of dilatation. — Lond. and Edin. Month. Juurn. Med. Set,, May, 1844. 

48. Fracture of the Malleoli. — M. Berard read to the French Academy of 
Medicine, Jan. 8th, a report on a memoir by M. Laserre on fractures of the ex- 
ternal and internal malleoli at the level of their articular surfaces. TJie memoir 
was founded on four cases. In the first, both malleoli were fractured at the 
level of the articulating surface of the tibia by a fall from a house. Amputation 
was performed, and the patient recovered. The second case was quite analogous: 
amputation was followed by death. In the third case, M. Laserre attempted to 
resect the fractured extremities of the bones; the operation did not succeed ; the 
limb was amputated, and the patient died. The fourth case terminated more 
happily; the fracture was transverse; both bones of the leg projected through 
a wound on the external surface of the joint. The fragments were reduced, and 
an ordinary apparatus applied. Union was completed in eight months. After 
fourteen months the patient resumed his usual occupation, and only suffered 
from stiffness of the joint. M. Berard first asked if it was not better to ampu- 
tate immediately in those cases when the parts seemed too much injured to hope 
to save the limh, than to make an useless attempt to do so after which that ex- 
treme measure had still to be resorted to] He also considered the question 
whether this was not a case in which subcutaneous section of the tendo-achiliis 
should be performed previously to attempting the reduction whenever tetanic 
contraction of the muscles of the leg opposed coaptation of the bones'? 

M. Velpeau considers resection as often the best measure in this accident. 
These fractures he stated are not always transverse, and when oblique it is 
almost impossible to effect reduction. Unquestionably, dividing the tendo- 
achillis would tend to facilitate the reduction, but in some cases, that proceed- 
ing would, M. Velpeau thought, be insufficient. Resection, on the contrary, 
renders reduction greatly easier, and also obviates recurrence of the displace- 
ment — moreover, it prevents or lessens the consecutive accidents (always very 
serious) caused by this fracture. Muscular contractions come on after reduc- 
tion, and are very likely to displace the bones again; but this event is much 
less liable to occur when the bones are shortened. — Dublin Med. Press, March 
27, 1844. 

49. BerthoWs method of arresting Hemorrhage from Leech-bites. — Cut a piece 
of caoutchouc, about one line thick, and half an inch square; hold one surface 
of it to the flame of a candle till it becomes softened and melted ; when it is 
cold rub it on blotting-paper, to make it smooth; then, having wiped off the 
blood, and compressed the bleeding point with the finger for a few minutes, 
apply the caoutchouc, and cover it with a strip of adhesive plaster. It should 
not be disturbed for some hours. — Prov. Med. Journ.j Feb. 24, 1844, from Bou- 
chardafs Annuaire de Therapeutique, 1844. 

50. Lithontriptic remedies. M. Boucharbat gives at some length a report 
by MM. Gay-Lussac and Pelouze on the subject of those remedies, on which 
they have experimented for two years. They first give the result of their expe- 
riments on stones out of the body, submitted to solutions of the bicarbonated 
and pure alkalis, of borax, and of the acids, which are any thing but encourag- 
ing; and then they observe respecting the internal administration of alkaline 
remedies, that although they do not profess to deny all the cases in which cal- 
culi have been reported to be dissolved, yet that they cannot help saying that 
those persons are labouring under a delusion who think that large calculi can be 
dissolved in a few weeks by these means. After hinting at the possible ill con- 
sequences which might arise from making the kidneys secrete alkaline urine 
during several months or years, they remark, that in a vast number of well au- 



1844.] V Surgery, 251 

thenticated cases, these medicines have only changed the diathesis^ and caused a 
lithic calculus to be coated with phosphates; or, after a lithic calculus has been 
removed, they have caused it to be succeeded by a phosphatic one. Besides, it 
is well known that the addition of an alkali to certain organic matters causes 
the formation of an acid. [It is well known that oxalic acid is prepared by 
heating wood with lime; and Prout has pointed out the possible origin of oxalic 
calculi in the improper administration of alkalis.] M. Prunelle, the inspector 
of the Vichy springs, has remarked that several patients, after beginning an 
alkaline course, have passed an immense quantity of lithic gravel and sand, 
which must have been of recent formation, for it was far too much to have been 
merely deposited in the kidney. Their experience of the results of injections, 
or rather irrigations of the bladder, were likewise any thing but encouraging; 
some uric calculi were softened by alkaline solutions, and one of the phosphatic 
variety was entirely dissolved by the dilute nitric acid after Sir B. Brodie's plan; 
but in most cases either the calculi remained untouched, or the patient was ob- 
liged to discontinue the treatment, through irritation of the bladder. 

MM. Gay-Lussac and Pelouze state that they have not been able to detect 
the hippuric acid in the urine of persons to whom the benzoic acid was admi- 
nistered, as was asserted some time since by Mr. Ure: but they several times 
observed that the urine of persons who were submitted to the experiment had a 
pleasant alcoholic smell, and kept for several days without apparent change. — 
Ibid. 

51. Removal of a diseased Ovarium ierminaii^rg fatally on the seventh day. — By 
T. M. Greenhow, Esq. — The patient was 29 years of age, and married. For 
four years she had suffered from frequent discharges of blood from the uterus. 
Eighteen months ago, six months after her marriage, the swelling in the abdo- 
men commenced at the pubic region, and rapidly increased till it attained a large 
size, her strength all the while declining, from the constant uterine discharge. 
The abdomen was tapped ; only a little blood escaped, but afterwards nearly a 
quart of dark-coloured fluid was discharged from the wound daily, for about a 
fortnight. 

Before the operation of removing the tumour, which was performed on Sep- 
tember the 3d, the abdomen was about as large as at the full period of utero- 
gestation ; there was fluctuation in one or two parts, but the tumour generally 
was firm, and felt as though divided into separate masses. The incision reached 
from a little below the ensiform cartilage to near the pubis. Several adhesions 
existed in different parts, the principal one being to the omentum, which was 
spread over the upper part of the right side of the tumour. These adhesions 
were divided with the bistoury, and then the tumour was raised, with some 
eflTort, owing to its great size and weight, and from its situation; double liga- 
tures were passed through its pedicle and firmly tied, and this part being divided 
near the tumour, it was liberated from its attachments and removed. Two arte- 
ries bled freely, one in the divided omentum and the other in the pedicle; upon 
these being secured, the wound was brought together by sutures and adhesive 
plaster, and a bandage applied. The operation was well borne by the patient, 
although she vomited several times towards the end ; the quantity of blood lost 
did not exceed six ounces. The symptoms which followed were chiefly great 
retching and vomiting; constipation of the bowels; quick pulse; tenderness 
and distension of the abdomen; and she died on the ifiorning of the seventh day. 

On the post-mortem examination the folds of the intestines and the omentum 
were found glued together by recently eflTused lymph. There was inflammation, 
with points of ulceration, near the pyloric orifice of the stomach. The uterus 
was healthy, but its cavities were lined with a vascular membrane, like the de- 
cidua. The morbid growth had been attached to the left broad ligament. On 
examining the tumour it was found to weigh twelve pounds seven ounces, and 
to be more than two feet in circumference. The surface was smooth and of a 
pale colour, resembling that of the skin. With the exception of a few cysts 
containing a yellow fluid, the general mass was composed of a dense and vas- 



252 Progress of the Medical Sciences, J^July 

cular cellular structure, with a membrane of small cells or cysts pervading its 
substance. The author concluded by making- some remarks on the case. He 
directed attention particularly to the disease found in the stomach, which he con- 
sidered had an important influence in leading to the fatal termination, and 
thought, on the whole, that the result of the case did not offer a strong argument 
against the resorting to a similar mode of treatment in such cases. — Lancet^ 
Jan. 20, 1844. 

52. Cr'se of alarming Syncope, from the admission of air into a vein during an 
amputation at the shoulder -joint. By B. B. Cooper, Esq. — The patient, a female 
nineteen years of age, was admitted on the 17th of May, 1843, under the care 
of the author, for enlargement of the middle third of the humerus. She had 
suffered pain in the seat of the disease for eight months, but the swelling did 
not commence till six weeks before her admission into the hospital. From the 
history and the examination of the arm, the tumour was considered to be a 
malignant disease of the bone, and amputation at the shoulder-joint was resolved 
upon. This operation was performed on the 23d of May. The arm was re- 
moved in less than a minute, and with very little loss of blood. When the limb 
had been severed from the body, the patient, who had borne the operation with 
great fortitude, expressed her thankfulness in a firm and audible voice. The 
subclavian artery was immediately secured, but its compression still retained 
upon the first rib, as there were small vessels requiring ligature. The author 
then proceeded to remove a gland, which was somewhat enlarged, from the 
axilla; and while dissecting it from its cellular attachments, he distinctly heard 
a peculiar gurgling noise, like air escaping with fluid from a narrow-necked bot- 
tle; and at the same instant the patient fell into a state of collapse, threatening 
immediate dissolution: the countenance was deadly pale; pupils fixed, and 
unobedient to light; the pulse quick, small, and fluttering, although at intervals 
regular; the respiration was irregular, being hurried and feeble, and attended 
occasionally with a deep sigh. The patient was directly placed in the hori- 
zontal posture, the flap brought over the wound, and retained by plaster; and 
various stimulants were administered. An hour elapsed before she was suffi- 
ciently recovered to be removed from the operating theatre. Upon being placed 
in bed, she passed her fa3ces and urine involuntarily. When the reaction was 
coming on, she uttered a continued whining cry, and maintained a constant mo- 
tion of alternate flexion and extension of the right leg, while the left remained 
perfectly quiescent, and seemed insensible to feeling, as well as motionless. She 
complained also of pain running up the right side of the head and neck. For 
several days she remained with her eyes closed. The lower extremities in the 
same condition as described, and the pulse very frequent. It was found neces- 
sary to give her opiates at different times, which relieved her general restless- 
ness, and procured sleep. On the fourth day, the left leg was also affected with 
involuntary contractions; but these subsided on the following day. On the 25th 
day she was able to leave her bed. The motions of the right leg had ceased at 
this time, but she complained of great numbness and loss of power in the left 
leg. On the 3d of July she was sufficiently recovered to leave the hospital, 
having no other unfavourable symptom but a slight dragging of the left leg. The 
author concluded his paper by adding remarks on the consequences of air being 
admitted into the veins, and pointed out the resemblance between the symptoms 
in his case and those presented in other similar cases upon record, as well as in 
experiments upon the lower animals, made to elucidate the subject. He drew 
attention to the different effect produced in man compared with brutes by the 
admission of air, owing to the influence of mental agitation on the motions of 
the heart in the former. He also dwelt on the various modes of death in such 
cases, according as the air introduced distended and paralyzed the walls of the 
right cavities of the heart, or was sent onwards, mixed with the blood, to the 
lungs, or was transmitted by the arteries to the brain; and he ended by offering 
some practical remarks on the best mode of guarding patients from such danger- 
ous occurrences in operations about the neck and shoulder.—Lonc?. Med. Gaz.t 
Dec. 1843. 



1844.] Surgery, 263 

53. Dissecting Aneurism of the Ascending Aorta bursting into the Pericardium 

Dr. Lees exhibited to the Dublin Pathological Society^ a specimen of an unusual 
variety of aneurism of the ascending portion of the arch of the aorta. The sub- 
ject from whom the specimen was derived was a woman about sixty years of 
age, who was apparently in perfect health on the day of her death, which 
occurred during the last week. After breakfasting heartily, she suddenly 
screamed, fell back, and expired in five minutes. On opening the pericardium 
a large quantity of coagulated blood was found interposed between it and the 
heart, which was adherent at several points to the pericardium, evidently the 
result of a former attack of pericarditis. The heart was hypertrophied. There 
was a rent about two inches long in the cellular coat of the posterior wall of the 
ascending aorta. The longer axis of this rent corresponded to that of the artery 
just where the pericardium is reflected from the aorta on the pulmonary artery. 
The external and middle coats of the aorta in this situation were separated from 
each other for a considerable space by a quantity of coagulated blood, which 
reached superiorly as high as the junction of the transverse with the descending 
portion of the arch, and inferiorly as low as the base of the heart. The cellular 
coat having been slit up anteriorly, there was brought into view a large trans- 
verse rent in the internal and middle coats, not coinciding with the opening in 
the external coat. It was about an inch in extent, and was situated in the ante- 
rior wall of the ascending aorta, at the distance of an inch and a half above the 
heart. There was an atheromatous deposit in the mitral and aortic valves, and 
also between the internal and middle coats of the aorta and of the large vessels 
arising from the arch. — Dublin Journ. Med. Set., March 1844. 

54. Diffuse Cellular Inflammation following Vaccination. — The first was that 
of a female child, aged five years, who had been vaccinated by a respectable 
practitioner in this city. This child was brought to me about three weeks after 
it had been inoculated. The arm was then greatly swollen, the swelling extend- 
ing to the hand ; the integuments of the upper arm were of a dusky leaden hue, 
and a large black slough occupied the situation of the usual crust of the vaccine 
vesicle. The child's pulse was weak and slow, not exceedinij" 64. The extre- 
mities were cold ; tongue dry and coated. There was stupor almost amounting 
to coma. There were extensive sloughing and hemorrhage from the mucous 
membrane of the mouth. The integuments of the cheeks adjoining the com- 
missure of the lips werd of a livid hue. The respiration was very much hurried, 
but no physical sign of disease could be detected in the chest. These formida- 
ble symptoms, I was informed by the child's parents, first presented themselves 
between the ninth and twelfth day from that on which it had been vaccinated. 
The practitioner who inoculated the child assured me that up to that period the 
vaccine vesicle ran a healthy course, and that he had vaccinated other children 
■with the same lymph in whom the course of the vesicle was perfectly regular. 

This child was of a delicate constitution, having been at times under my care 
for attacks of scrofulous ophthalmia, pneumonia, and bronchitis. Its health, I 
understood, was good at the time it was inoculated. 

Complete recovery, though very slowly, was effected in this case by the fol- 
lowing means: — The child's strength was supported by the exhibition of mild 
tonics and of the diffusible and permanent stimulants. The arm was kept 
constantly poulticed and fomented, until the sloughs separated, and was then 
dressed with simple dressings. Muriatic acid, slightly diluted, was occasion- 
ally applied around the sloughs of the mucous membrane of the mouth, and at 
times small doses of opium were given. 

The second case was that of a male child, aged eighteen months, who was 
also vaccinated by a physician of character in this city. About the twelfth day 
from the period on which it was vaccinated, the arm was attacked with severe 
inflammation of the erysipelatous character, the vaccine vesicle, as far as I could 
collect from the parents, having, up to that day, ran a regular course. I saw 
this child on the sixteenth day. A dark slough, as large as a shilling, then oc- 
No. XV.— July, 1844. 22 



254 Progress of the Medical Sciences. [July 

cupied the situation of the vesicle ; the entire extremity was imniensely swollen ; , 
the integuments of the upper arm were of erysipelatous redness, and such por- 
tions of them as were in the immediate neighbourhood of the slough were quite 
livid. The attending fever was of the inflammatory type, the skin being hot, 
tongue furred, pulse rapid and full, and the thirst great. Until the fever was 
subdued by cooling and alterative medicines, and the local inflammation relieved 
by the application of poultices and fomentations, the sloughing spread with the 
most alarming rapidity. After the sloughs had separated, the progress of the 
gangrene having been arrested by the foregoing treatment, a large and deep 
ulcer remained, with undermined edges, at the bottom of which the muscles of 
the arm could be distinctly observed ; so extensive was this nicer, that it was 
not healed for three months, though the case progressed most favourably in 
every respect. The child, I was informed, was in good health at the time it 
was inoculated; and I saw other children who, I was told by their parents, were 
vaccinated by the same matter in whom the vaccine vesicle ran a regular 
course. 

It is obvious, if the accounts which 1 received were correct, that the unhealthy 
inflammation in the foregoing cases could not have bee-n produced by the inocu- 
lation of impure matter, as other children were vaccinated with the same lymph 
without any deleterious consequences; the period also at which the inflamma- 
tion supervened militates against such a supposition. Dr. Dwyer and Dr. 
Battersby, who, as I have just mentioned, saw the last of these two cases, 
concurred with me in the opinion that the very severe inflammation which 
attacked the arm must have arisen from some peculiarity in the child's consti- 
tution, or from some local irritation. The fever and symptoms which existed 
in the first case, appear to have been very similar to those symptoms which 
attend one of the malignant forms of scarlatina described in Dr. Graves' work, 
styled secondary fever in my paper published in it, and aptly termed compli- 
cated malignant by Dr. Henry Kennedy. I'here could have been no complica- 
tion in this case with scarlatina, as the child had been aflfected with that disease 
at a remote period from that in which it was vaccinated. 

I have recorded these cases not with the slightest idea of creating any preju- 
dice against vaccination, which has proved so eminently useful, but for the 
purpose of showing its analogy to the other exanthemata, and with a view of 
rendering practitioners cautious in the management of children whom they have 
vaccinated, until all inflammation has ceased. — Duh, Journ. Med, Set. 

55. Ununited Fracture treated by Acupunduration. — A man of a good constitu- 
tion, aetat. 26, met with a simple fracture of both bones of the forearm. Five 
weeks after the accident no union had occurred, and the apparatus was again 
applied, and the limb kept in a state of perfect rest during four weeks longer. 
At the end of this time, finding the fragments still ununited, M. Wiesel deter- 
mined upon the employment of acupunduration which he did in the following 
manner. 

Between the fragments of the ulna he introduced two needles long enough 
to pass completely through the false joint, and allowed these to remain in place 
during six days, by which time they had produced great tumefaction of the part 
and caused much pain. Fifteen days after this, a similar operation was done 
upon the radius, which, after a few days, was followed by acute pain and slight 
suppuration. After the application of the needles the arm was carefully sup- 
ported in splints, and at the end of six weeks consolidation was found to be 
complete. — Gaz, des Hopilaux, Dec. 1843, from Giornale per servire ai progressi. 



1844.] Midwifery. 255 



OPHTHALMOLOGY. 

56. Chloride of Sodium in diseases of Ihe Eye. — In a report (see No. for Aug. 
1840) of cases treated in Wills' Hospital by the editor of this journal, he re- 
commends in certain conditions of the conjunctiva, as a useful application, a 
saturated solution of common table salt. This remedy has since been employed 
by others, and with favourable results. 

M. Tavignot has recently made extensive use of this substance, as a local 
application, in different forms of inflammation of the eye, and more particularly, 
in ulcerations of the cornea, and recomniends it as being- not only as efficacious, 
but even more so than nitrate of silver, and other substances commonly applied 
in such cases. At the same time, it is less likely to produce permanent irritation, 
or act as an escharotic. He has employed it, Isi, In the solid form. The crys- 
tals of common salt are ill adapted for this purpose, from their want of cohe- 
sion ; but with a little practice a piece may be obtained capable of being- filled 
into a caustic-holder, and used in the same manner. Another way of applying 
the substance, is in the form of a fine powder introduced into the eye; its action 
will then become prolonged, and as a consequence, be more energetic. This, 
however, might be an advantage in various cases, not readily yielding to other 
modes of treatment, as for example, purulent ophthalmia. As compared with 
the nitrate of silver, or sulphate of copper, the use of the chloride of sodium in 
the solid form, is preferable, because there is no danger, as with these substances, 
of its destroying the tissues, its action being merely irritant. The application 
of chloride of sodium causes pretty smart pain at tlie instant, but this soon sub- 
sides. 2c?, In the form of ointment. This may be made in the proportions of 
from 1 to 4 drachms of powdered common salt, to the ounce of lard. It is best 
to begin with the weakest form, and afterwards gradually to augment its strength. 
In granular conjunctivitis, and inflammation of the ciliary margins, — affections, 
it is well known, of a very obstinate character, — it has been of signal benefit, 
3(f, As a collyrium. 'J'his is the best form of using the application. Several 
cases are given of its success in ophthalmia, and ulcerations of the cornea. The 
strength of the solution may vary from 1 to 3 drachms to the ounce of water. 
One drachm to the ounce will be found sufficiently strong for most slight cases. 
— V Experience^ Dec. 1843. 

57. Cyanide of ZAnc in Ulcers and Opacities of the Cornea. M. Cabrier is of 
opinion that preparations of hydrocyanic acid have great eflRcacy in promoting 
cicatrization of ulcers of the cornea and the removal of opacities. The compound 
he prefers is the cyanide of zinc, in the form of ointment, in the proportion of 1 
part of the salt to 25 of lard. — BuuchardaCs JLnnuaire de l^erapeutiqiie, 1844, 

58. Conical Cornea. — Dr. Jaimes H. Pickford relates, in the Dublin Journal of 
Med. Sci., some cases of conical cornea successfully treated by the administra- 
tion of an emeto-purgative, at first daily, and then once or twice a week. He 
uses the sulphate of zinc with sulphate of magnesia. 

The efficacy of this treatment we conceive needs confirmation. 



MIDWIFERY. 

59. Signs of Pregnancy. — The changes in the condition of the os and cervix 
nteri during pregnancy have been investigated by MM. Filugelli, Chailly, and 
Cazeaux. The results they have arrived at agree on the whole with llinse of 
Birnbaum, M. Filugelli, indeed, appears to have fallen into the error of ima- 



256 ^ Progress of the Medical Sciences. [July 

gining- that the cervix uteri becomes actually elongated in the course of preg- 
nancy ; and M. Chailly's paper is principally occupied with a refutation of this 
opinion ; the slight enlargement which may possihly result from tumefaction of 
the cervix at an early period of pregnancy being in his opinion too slight to be 
appreciated. M. Cazeaux's conclusions are: 1. That a softening of the texture 
of the cervix uteri takes place from the very beginning of pregnancy, being for 
the first few months confined to iis lower part, but extending from below up- 
wards, and taking place less rapidly and in a less marked degree in primiparae 
than in those who have already borne children. 2. While this softening goes 
on, the cervix dilates; presenting in those who have had children the form of a 
funnel with its base downwards, while in primiparae it is more spindle-shaped. 
3. The OS uteri is closed in primiparae, until the end of pregnancy; in women 
who have borne children it is widely open, forming the base of the funnel. 4. 
As a general rule, no real shortenino- of the cervix takes place until about the 
lastfortnightofutero-gestation. — West's Report /m B. ^ F. Med. i?ey., April, 1844. 

60. Watery discharge from the Vagina during Pregnancy. — M. Chailly in a 
paper on watery discharge from the vagina during pregnancy^ adopts the opinion 
of Naegele, that the fluid is secreted by the uterus, and not in any way derived 
froai the ovum. The fluid, as it is accumulated, detaches the membranes from 
the walls of the uterus, and a pouch is thus formed in which it is contained 
until reaction of the uterus is excited. The contractions of the uterus, however, 
detach the membranes partially from the cervix; and the fluid escapes in gushes 
through this aperture, an occurrence that is sometimes painless, sometimes at- 
tended with pain about the loins and pelvis. Several cases are related to prove 
tliat the uterus, and not the ovum, is the source of this fluid. Thus, a woman 
in the eighth month of pregnancy suddenly discharged two quarts of reddish, 
fluid from the vagina; and though no sign whatever existed of commencing 
labour, a similar discharge continued for six days. At the full period labour 
came on, and it was found necessary to rupture the membranes artificially, when 
a large quantity of perfectly limpid liquor amnii escaped.— /6ic?. 

61. Ulceration of the Cervix Uteri. — Dr. Cortilhes calls attention to the fre- 
quent complication of pregnancy with ulceration of the cervix uteri. These ulce- 
rations are frequently caused by the previous occurrence of abortion, and in 
many instances exist before the commencement of pregnancy. The symptoms 
to which they give rise, however, may be so slight as not to attract notice while 
the patient is unimpregnated, though on the occurrence of pregnancy they gene- 
rally become very marked; while utero-gestation renders the ulcers very indis- 
posed to heal, or even prevents their cicatrization. The ulcerations are always 
associated with engorgement of the cervix uteri, which is more considerable in 
the early months of pregnancy, than at a later period, and they invariably give 
rise to pain in the lower part of the abdomen. They are usually of an irregu- 
larly circular form, four or five lines in diameter, and one or two deep, and have 
a fungous surface covered with dark red, almost violet-coloured granulations. 
The ulceration usually begins around the edge of the os uteri and thence ex- 
tends, giving rise to a thick, yellowish white discharge. Should the disease 
occur in the earlier months of pregnancy, the ulcerations will often advance, 
though very slowly, towards cicatrization, and utero-gestation continues undis- 
turbed. When the ulceration supervenes at a later period, no attempt is made 
at cicatrization, and premature labour comes on unless the woman be subjected 
to proper treatment. This tendency of the disease to induce premature labour 
constitutes its gravity; but M. Cortilhes regards it as very amenable to treat- 
ment which consists in the local employment of caustics and the use of astring- 
ent injections. — Ibid. 

62. Pelvis ^formed by Osieomalatia — yielding during Labour. — Dr. SpENGELin 
a dissertation written under the auspices of Professor Naegele, describes two 
cases, neither of which, however, came under his own observation, in which the 



1844.] Midwifery. 257 

pelvis deformed by osteomalatia yielded so as to admit the passage of the child 
during iahour. — Ibid. 

63. Malposition of the Uterus as an impediment to Labour. — Dr. Perfetti at- 
tended a woman in lahoiir who had complete procidentia of the uterus. She had 
suffered more or less from prolapsus uteri ever since she was fifteen years old, 
and on any great exertion the organ appeared externally. Having hecome preg- 
nant at the age of twenty-two, she was relieved from her ailment until the seventh 
month of utero-gesiation, when it began to return ; at the beginning of the eighth 
month the uterus reached more than six fingers' breadth beyond the external 
parts, and during labour it projected still further. After being four days in 
labour, Dr. Perfetti visited her, and found the os uteri so hard and undilatable 
as to require incisions to be made into it. He then introduced the forceps into 
the uterus, and extracted the child. The mother recovered, but the prolapsus of 
the uterus rendered it necessary for her to wear a pessary. Dr. J. Ledesma, of 
Salamanca, has recorded the history of a woman, aged forty-two, the mother of 
six children, who was affected with inguinal hernia on the right side. In the 
third month of her seventh pregnancy the hernial swelling suddenly increased in 
size; and continued progressively to enlarge up to the period of labour, utero- 
gestation being undisturbed by this accident. When labour began, the hernial 
tumour measured twenty-four inches in length, and twenty-six in circumference 
at its broadest part ; its base reached to the crural arch, and its weight had drawn 
the right labium considerably downwards. When labour-pains came on, which 
were attended with a slight discharge of liquor ainnii from the vagina, an inci- 
sion was made into the tumour, and a living female child, twenty-two inches in 
length, was extracted. The patient would not submit to the division of the ad- 
hesions by which the uterus was confined to its abnormal position, and conse- 
quently the hernia was not reduced. In forty days from the date of the opera- 
tion, the patient was sufficiently well to attend to her household duties. [This 
case is very similar to that which recently occurred to Dr. Fischer, of Berne, 
mention of which is found in many of the English journals, except that Dr. 
Fischer's patient died. Reierences to other similar cases will be found in Busch, 
Geschlechisleben des Weibes, iii Band, Seite 647.] — Ibid. 

64. Rupture of the Uterus terminating favourably .— Y om cases of this have lately 
been recorded in which the patients recovered.* Dr. Mitchell's patient was 
thirty-eight years old, and the mother of six children. From the sixth month of 
pregnancy she had suffered very severe pain at the lower part of the abdomen. 
Labour proceeded favourably for the first twelve hours, when sudden collapse 
and vomiting occurred. The patient was delivered by the crotchet, and it was 
then found that a rupture existed at the anterior part of the cervix uteri. Ex- 
treme irritability of the stomach, and very intractable diarrhoea were the most 
prominent symptoms that followed her delivery. Opium was given in large 
and frequently repeated doses, both by the mouth and enemata, and on the 
thirty-first day after her delivery, she was sufficiently recovered to be removed 
to her own home. M. Castelly performed gastrotomy on his patient three hours 
after the rupture of the uterus had occurred, and extracted the placenta, as well 
as the child, through the wound. Severe metro-peritonitis followed the opera- 
tion, but the patient ultimately recovered. Six months afterw^ards she menstru- 
ated ; and nine months afterwards aborted at the third month. The accident to 
Dr. Vaulpre's patient appears to have been produced by repeated unsuccessful 
attempts to deliver with the long forceps. Dr. Van Cauwenberge's patient had 
undtirgone the Caesarian section fourteen months before. When in the seventh 
month of pregnancy labour-pains came on ; symptoms of ruptured uterus oc- 
curred, and the child passed into the abdominal cavity. The exhausted condi- 

* Dr. MitcheM. Dublin Journal of Med. Science, J;m. 1843. M. Castelly, Bull, de 
I'ACiid. Roy.df Mel Sept. 30, 1843. D. Vauljjie, Gaz. Med. Mars 18,1843, Dr. V. 
Cauwcubcrge, rt^xpericnce, Nov. 18, 18^3. 

22* 



258 Progress of the Medical Sciences. [July 

lion of the woman appeared to forbid all interference, but between the fifteenth 
and twentieth day after the accident happened, the cicatrix of the abdoni'nal in- 
teguments gave way, and a putrefied foetus, with its appendages, was extruded. 
M. Danyau recommends that the suture should be applied in cases of laceration 
of the perineum, immediately on the occurrence of the accident, instead of wait- 
ing till the patient has recovered from her labour, when it would be necessary 
to refresh the edges of the wound before applying the suture. The authority of 
M. Roux is directly opposed to M. Danyau's plan; but M. Danyau asserts that 
the degree of tumefaction which follows a rent of the perineum has been exag- 
gerated, whilst the suture tends to diminish it, and if proper attention be paid 
to the introduction of the catheter, and the frequent use of vaginal injections, 
neither the lochias nor the urine will seriously interfere with the healing of the 
wound. On the other hand, if the operation be delayed, it becomes almost im- 
possible to bring the edges of the wound into contact. In support of his opinion 
he relates six cases ; in five of which the perineum was torn up to, but not into 
the sphincter, and the operation was successful ; in the sixth, the sphincter too 
was involved, and there was considerable ecchymosis about the edges of the 
wound. The operation, in this instance, failed, sloughing of the parts having 
taken place on the fourth day after delivery.— /6z<i. 

65. Turning in Arm Presentations. — Dr. Hutter, of Marburg, has wrjtten a 
Ijengthy paper, in which he recommends turning to be practised without^uptur- 
ing the membranes, in some cases of arm presentation. The operation is much 
the same as that practised by Michaelis, when prolapsus of the cord occurs, and 
consists in the introduction of the hand between the uterus and the membranes, 
until the operator reaches the feet, knee, or other part, when, without rupturing 
the membranes, it will be extremely easy to turn the child. He practised this 
manoeuvre in five cases, but in three the same person was the subject of the ope- 
tion. In four of the five cases the child was saved, and in one instance the mo- 
ther had previously lost two children by the ordinary mode of turning. He 
recommends this practice as disturbing the ordinary course of labour much less 
than the usual mode of turning, since the rupture of the membranes is left to 
nature, and the case may be afterwards managed as if the presentation had been 
natural from the beginning. The whole quantity of the liquor amnii being avail- 
able in this operation, its performance is greatly simplified, while it has the fur- 
ther advantage of avoiding the prolapse of the cord, or of admitting of its reposi- 
tion, should that accident have occurred. He denies that the uterus would be 
much irritated by this proceeding, and asserts that the membranes would be 
stret(;hed, and forcibly separated from the uterus, or the placenta partially de- 
tached, only, if the operation were attempted before the os uteri is sufficiently 
dilated, or if the membranes were morbidly adherent, while auscultation would 
always be an adequate guide to the situation of the placenta. [These arguments 
do not appear by any means conclusive; the various favourable circumstances 
which, according to Dr. Hutter, warrant the operation, are not found often to 
coincide, and the hazard of detaching the placenta is probably much greater than 
he represents it to be. His assertion, too, that auscultation would invariably 
guide to the situation of the placenta is incorrect, for in one hundred and eighty 
out of six hundred cases, in which it was resorted to by Naegele, or in thirty per 
cent., it was not possible to determine the seat of the placenta.] — Ibid. 

66. Partus siccus. — A case of this is detailed by M. Matthysen, in which 
the patient was delivered of her first child after a quick labour, but in which no 
discharge of liquor amnii either preceded or followed its birth. The placenta 
came away naturally, the uterus contracted well, and though the lochias were 
exceedingly scanty, no accident occurred in the puerperal state. The child was 
born alive, full grown, hut extremely thin, and its skin was covered by a thick 
coating of vernix caseosa. [M. Matthysen erroneously supposes this tn be the 
only case of the kind on record ; instead of which many cases have been related 
since attention was first called to it by JRudolphi.] — Ibid. 



1844.] Medical Jurisprudence and Toxicology. 259 

67. Jlbuse of Obstetric Manoeuvres. — MM. Pereira and Lasserre, formerly 
internes at the Maternite, have published an essay on the abnse of various obste- 
tric manoeuvres, the accidents to vi'hich they give rise, and the advantages of 
temporizing in the practice of midu-ifery. Many cases are related, illustrative 
of the evil consequences of forcible dilatation of the cervix uteri, and of the 
application of the forceps, with no other indication than the slowness of the 
labour. In this last category sthere are related several cases of laceration of the 
vagina, and rupture of the uterus, and the remarks of the writers on these acci- 
dents form the most valuable part of the paper. They next endeavour to show, 
by the evidence of statistics, that the danger to the mother's life, from the mere 
prolongation of labour, is less than the danger to which she is exposed when 
the labour is terminated by manual or instrumental interference. — Jbid. 

68. Neiu Perforator. — Dr. Smith,* of Glasgow, has invented a new perfo- 
rator ; the blades of which expand, by means of a screw, much in the same 
way as the blades are separated in Weiss's speculum. He conceives that by 
this modification some of the dangers incidental to the employment of the ordi- 
nary perforator are avoided. Various attempts have been made to improve 
Baudelocque's cephalotribe; many of these devices display much ingenuity, 
but at the same time add greatly to the complication of this formidable and, it 
may, perhaps, be added, useless and dangerous instrument. — Ibid. 

69. Complete Congenital Inversion of the Uterus. — M. Williaume, of Metz, com- 
municated to the French Academy of Medicine, Sept, 12, 1843, a case of a very 
peculiar disposition of the uterus; this organ was inverted, so that the body of 
the uterus was below and formed a tumour on the right side of the vagina, while 
its neck was above and completely out of reach of the finger. On examining 
the hypogastrium, or through the rectum, no trace could be detected of the 
womb in the situation it usually occupies. This disposition of the parts is con- 
genital ; the girl in whom it occurs is a virgin accustomed to a sedentary life, 
and has never made any exertion which could have occasioned it. She men- 
struates regularly, which excludes the idea of occlusion, but the menstrual dis- 
charge finds exit with difficulty, and imperfectly, and at the period of the cata- 
menia, accumulates in part in the uterus, and distends it, so that a certain 
pressure must be exerted on the organ to empty it entirely and restore it to its 
natural size. The menstrual blood is always mixed with a copious leucorrhceal 
discharge. A consultation of physicians was held at Metz, and, considering 
that the affection was congenital, and the uterus so immovable that no effort 
could remove it from its abnormal situation, it was determined that marriage 
should be interdicted, because conception might take place, but delivery would 
be apparently impossible. — Dub. Med. Press, Nov. 8, 1843. 



MEDICAL JURISPRUDENCE AND TOXICOLOGY. 

70. Death from Corrosive Sublimate applied to an Excoriated Surface. — A child 
two years old, had, at the bottom of the cutaneous folds of the thigh, several 
small chaps. The mother was in the habit of sprinkling the denuded surface 
with the powder of cycopodium. One day, by mistake, she took from the cup- 
board, a nearly similar powder, yellowish like it, but hard to the touch, and 
which afterwards was ascertained to be impure corrosive sublimate. She used 
it to powder the upper part of the thigh and scrotum. Piercing cries followed, 
and in twenty minutes a brown scar was formed on the parts that had been 
powdered. Around was an inflammation of a bright red colour. 

A physician caused the child to be bathed two or three times, and thirty hours 
after the accident it was taken to the hospital. The scar was now black and 

* London and Edinburgh Monthly Journal, Nov. 1842. 



260 Progress of the Medical Sciences, [J"^y 

dry in the centre and rather humid at the circumference. The child showed no 
functional disturbance, but at the end of forty-eight hours the gums swelled, 
became painful, and were covered with white pellicles; the breath became fetid, 
and the submaxillary glands swelled considerably. Gradually the inflammation 
extended over the whole mucous membrane of the mouth, scars showed them- 
selves on the gums and on the internal surface of the cheeks; beneath them the 
flesh was fungoid and bloody. Afterwards the jaw-bone was denuded, and con- 
siderable hemorrhage ensued. The blood swallowed by the child was passed 
under the form of a blackish liquid, once by vomiling, and once by stool. The 
breath was extremely fetid, and the salivation well characterized. Fever set up 
only after seven days; the face altered but little before death, when the flesh, 
became flabby, and the skin assumed a dull and grayish colour. — Chemist^ Feb- 
ruary, 1844, from Gazette des Hopilaux. 

71. Diseases of the Uterus compatible with Pregnancy. — T have, in another 
place, endeavoured to show that the study of Medical Jurisprudence, apart from 
its value in aiding the just administration of the laws, has a secondary advan- 
tage, viz., that it establishes, from time to time, the correctness or incorrectness 
of medical opinions on doubtful points, by bringing all the knowledge, either of 
facts or of functions that we possess, to bear at once on a particular inquiry. I 
adduce, in illustration of this, ihe subject at the head of this article. When I 
commenced the examination of the science, cancer of the uterus was placed by 
Fodere, the then principal authority, among the absolute causes of sterility, and 
I observe that he quotes the name of .Morgagni in support of it. With the pro- 
gress of investigation, this has been ascertained to be an incorrect opinion. Dr. 
Beatty, of Dublin, had a pregnant female labouring under the disease, and Dr. 
F. H. Kamssbotham observes, in his lectures, {^London Medical Gazette, vol. 16,) 
that in one case, at least, which he attended, he had an opportunity of knowing 
that the disease existed before impregnation. Dr. Waller {Lancet, February 29, 
1840,) mentions an instance where the female passed safely through her de- 
livery, but died after intense suffering, in six weeks thereafter. The uterus was 
completely destroyed by ulceration. 

Dr. Lever, in his late work on Organic Diseases of the Uterus, mentions six 
additional cases. Abortion is, however, a common occurrence. "In two of the 
six it would seenj that the foitus was small and under the standard size, in 
a third it was dead, (although the woman conceived subsequently, and gave 
birth to a living seven months' child,) and in a fourth it must have been dead 
for some time before delivery, for the cuticle was peeling oflT in several parts." 

The following facts are also stated by Dr. Lever. "Eighty-one women, 
labouring under organic uterine disease, conceived 553 times; 43 conceptions 
terminated in abortions, and 510 children were born at the full time. Of these 
610 children, twelve only were still-born. Subsequently he witnesses three 
other cases in which the infants were still-born, in all of which the mother 
laboured under encephaloid cancer. In these the death of the child was clearly 
traced to the protracted labour, and consequent pressure on the head, owing to the 
non-dilatability of the parts through which the child had to pass." — From Review 
of Dr. Lever'' s Work in Medico-Chirurgical Review, and Edinburgh Medical and 
Surgical Journal fur January, 1844. T. R. B. 

72. JLction of Alcohol and Ether on the Animal System.— W\\.^Q\\ex\\(i\\ has insti- 
tuted several experiments with these substances, and the following are the 
results, as given by Dr. Simon in his Medical Chemistry. 

Anhydrous alcohol {absolute alcohol, or alcohol absolutely free from water) 
was the article used. Rabbits, into whose stomachs one ounce of anhydrous 
alcohol had been injected, fell in a short time into a state of great faintness; 
sensation and motion were diminished, so that the animals could no longer keep 
themselves upright; the pulse and respiration were very much hurried, and 
death followed from one hour atid a half to two hours without any convulsions. 
On examination, iimmediately after death, the alcoholic odour was palpable, the 



1844.] Medical Jurisprudence and Toxicology. 261 

muscles still contracted when mechanically irritated, the peristaltic motion of 
the intestinal canal was weak, the stomach was found to be very much inflamed, 
the colour of the small intestine was not changed, the gastric contents smelt 
strongly of alcohol, and were partly coagulated. "The chemical action of 
alcohol on the coats of the stomach was placed beyond all doubt; tiie epithelium 
was detached only in some places; it was of a gray-white colour, easily torn, 
the form of its cells were changed, and they appeared, as it were, shrivelled up. 
The vascular membrane was of a dark-red brown, full of blood, and penetrated 
with a partly clear or reddish-coloured exudation, whereby it was increased in 
thickness, but the exudation itself was not coagulated; the muscular and peri- 
toneal coats were not much altered, the small irUestine was little changed; the 
large intestine, the lungs, heart, kidneys, and liver, were in their natural state; 
the brain and vessels of the cerebral membrane were not very much filled with 
blood, nor was any exudation perceptihle; the blood did not appear in any W'ay 
changed, nor could the odour of alcohol be detected. Dilute alcoholic fluids pro' 
duce no chemical change in the coats of the stomachy but in the case of persons of 
temperate habits, chemical reactions are to be apprehended from the immoderate use 
of a fluid containing forty per cent, of brandy.''^ 

Ether does not appear to exercise a chemical action on organic matters. A 
drachm of it was injected into the stomach of a rabbit. The animal seemed but 
little excited by it, but became very soon insensihle, and fell on its side; the 
body became tympanitic, and after fourteen minutes death followed without 
spasms; on opening the body the smell of the ether was very perceptible, the 
stomach and small intestine w^ere much inflamed, but the cells of the gastric 
mucous membrane did not differ much from their natural state; in some cases, 
where the mucous membrane was covered with blood, the epithelial cells were 
swollen to about six or eight times their natural size; the vascular membrane 
was much injected, the muscular and peritoneal coats were not changed; the 
small intestine was inflamed, and contained much ether. If, in cases where 
large doses of ether were given, deatli followed very soon, the intestinal canal 
was not changed. Sometimes ihe animals die of suffocation amid the rapid 
evaporation of the ether. The ether accordingly occasions violent inflammation 
of the stomach and intestinal canal; it penetrates the membranes, and is then 
conveyed into the blood-vessels. A chemical action on the tissues could not be 
perceived. — Medico-Chirurg. Bev., January, 1844. 

73. Poisoning of Children by coloured Confectionary and Paints. — The French 
and German journals frequently contain accounts of fatal accidents from the 
above causes, and I doubt whether sufficient attention is paid to the subject in 
this country. 

Dr. Beer, of Vienna, was called to five children, aged from three to eleven 
years, who had eaten of those coloured bonbons., of which sugar is the principal 
constituent. Some were seized immediately after eating, others a few hours 
afterwards. The symptoms were great thirst, headache, vertigo, nausea, dry- 
ness of the mouth, vomiting of a dark brown or green matter, severe pain in the 
bowels and tenderness to the touch, retention of urine, obstinate constipation, 
with constant tenesmus, and cold sweats. These were succeeded by violent 
pains in the head, light delirium, spasms and somnolency, which last, in three 
instances, was followed by coma. In a patient eleven years old, diarrhoea 
occurred, and in another a vomiting of mucus and blood. 

All, however, recovered by the antiphlogistic treatment and external stimulant 
applications, hut a difficulty in passing urine continued for several days in two 
of them. On examination, by a competent chemist, these sugar meats were 
found to contain a notable proportion of oxyde of copper. {Oesterr Med. Wo- 
chenscrift.) 

As to cakes of paint, Dr. Lewensten, of Berlin, witnessed the poisoning of 
a child from biting one of green ink, and which, when analyzed, proved to be 
composed of arsenite of copper. 



262 Progress of the Medical Sciences, [Ju^y 

Another child in Paris amused itself by attempting to make pictures with the 
colours in a paint-box, and, as is quite common, effected this by moistenlnor the 
end of the cake in its month. It was shortly after seized with all the symptoms 
of poisoning, from which it was relieved by early remedies. The parents, 
desirous of ascertaining the cause, requested M. Regnard to examine the paints. 
He ascertained that the one used by the child, which was of a dark green, con- 
sisted of cyanuret of iron and chromale of lead ; two others consisted of arse- 
nite of copper. 

Mr. Regnard adds that the yellow paints are thus coloured by gamboge or 
chromate of lead ; the red with cinnabar, or the red oxyde of lead; the white 
with white lead ; the blue with carbonate of copper, while tlie green are coloured, 
as above stated, with arsenite of copper, (Scheele's green,) or a mixture of 
Prussian blue and chromate of lead. 

Moral. — Never permit young children, or even those of a larger growth, to use 
water-colour paints away from the eye of the parent or nurse. — Encyclographie 
Des Sciences Medicales, Aug. and Oct., 1843. T. R. B. 

74. Toxicohgical Experiments wilh Nitrate nf Potash. Academy of Sciences, 
Paris, July 31, 1843. — MM. Mojon and Rognetta made a report of their 
experiments on rabbits wilh this substance, for the purpose of elucidating the 
following points. 

1. Is It true that nitrate of potash is not absorbed by the skin, as Orfila and 
other toxicnlogisls assert? Our experiments have given us directly opposite 
results. We have poisoned rabbits by injecting a solution of the salt into the 
subcutaneous cellular tissue. A full grown rabbit died in six hours after thus 
injecting 240 grains of nitrate of potash dissolved in 3^ ounces of water. 

2. When introduced into the stomach, what is the minimum mortal dose to a 
rabbit? Forty grains, dissolved in three and a quarter ounces of water, and 
injected into the stomach, killed rabbits in from thirty to forty hours. Twenty 
and even thirty grains did not destroy them, but death followed in from four to 
five hours, when sixty grains were injected. 

On dissection, in these cases, not the slightest mark of inflammation or ero- 
sion in the stomach, intestines, or kidneys, could be found. On the contrary, 
these parts were all pale and remarkably flaccid. The abdominal veins were 
alone gorged with blood. 

The most remarkable symptom attendant on these poisonings, was the extra- 
ordinary secretion of urine. It commenced almost immediately after the injec- 
tion of the salt, and continued until a very f^ew hours before death. 

3. Are there any antidotes to nitrate of potash? We regard its action as 
asthenic or debilitating, and hence believe that a stimulant treatment is best 
calculated to counteract its eff'ects. We dissolved forty grains in about three 
and a quarter ounces of light wine, and injected the mixture into the stomach. 
In all cases the animal survived the experiment; we hence conclude that the 
stimulant effect of alcohol will neutralize the poisonous qualities of nitrate of 
potash. 

Dr. Henry Bennet asserts that nitrate of potash may be safely given in large 
doses; (see p. 210, of this No.) 

He coincides in opinion wilh Mojon and Rognetta as to its sedative effects. 
This, indeed, is shown by the experiments of Orfila on animals. 

It is quite probable that the escape of individuals, after taking large quantities 
of saltpetre, may be susceptible of the above explanation. But may not the dis- 
ease present have some effect, like pneumonia on tartar emetic 1 T, R. B. 

75. On Poisoninghy Copper. By MM. Danger and Flandin. — The follow- 
ing process has enabled the experimenters to detect the hundred-thousandtli 
part of this metal mixed with organic matters. Carbonize the animal matters 
with one-third of their weight of sulphuric acid, and carry this process to a low 
red heat. Reduce the charcoal thus obtained to powder, add sulphuric acid 
sufficient to moisten it, and then boil the mixture, but not to dryness. If now 



1844.] Medical Jurisprudence and Toxicology. 263 

a solution be made in water, all the tests characteristic of copper may be used, 
with the certainty of a correct result. 

Tiiey totally dissent from the opinion that either copper or lead exists in the 
human body in its healthy condition. They are confirmed in this by direct ana- 
lysis, and also by a physiological experiment. 

During the nine months that they were engaged in their investigations on this 
metal, they mixed daily, with the food of a dog, sometimes sulphate and some- 
times acetate of copper. The dose was gradually increased, and the animal 
finally took, without any injury to his health, ten centigrammes daily, so that 
the whole swallowed, during 263 days, was not less than twenty-five grammes, 
(about seven drachms.) During life no trace of copper could be detected in the 
urine, and when killed none was found either in the bones, muscles, or viscera. 

Our authors also claim to have discovered a peculiar symptom, viz., salivation 
or a copious bronchial secretion, which ordinarily occurs in a few hours after 
the poisoning, and which is evidenily the mode in which the system frees itself, 
in the same manner as the kidneys eliminate arsenic and antimony. They 
detected the poison in this fluid, after having in vain long sought for it in the 
urine. When the secretion ceased, the animal swallowed, with its saliva, the 
fluid of the bronchial respiration, and then they delected the copper in the intes- 
tinal excretions. 

This diflTerence in the mode in which nature acts to expel the poison, leads 
MM. Danger and Flandin to suggest various modifications in the treatment of 
cases of poisoning by copper. Commence with chemical neufralizers, as iron 
filings, sulphuric lemonade, and eraeto-cafhartics ; then general and diffusible 
stimulants, sudorifics and vapour baths, and finally, employ the remedies indi- 
cated to remove local inflammation. 

As to other poisons, chloride of gold passes off in much larger quantity by 
the kidneys than by the lungs; while it is directly the opposite with chloride of 
silver. Of the poisons that pass most readily by the kidneys, antimony has the 
first place, next gold, arsenic, silver. Copper is certainly at the foot of the list, 
and they doubt whether it should not be altogether excluded, since the organs of 
the renal secretion appear to be impenetrable to it. 

After death, it is exclusively in the intestinal canal and the liver that we can 
detect the presence of copper. From an ounce and a half to two ounces of the 
latter viscus, contain sufficient for the most decisive judicial proofs. — Royal 
Academy of Sciences nf Paris^ Meeting of July 24, 1843. T. R. B. 

76. Medico-ks;al Observations on Foot Prints. — M. Mascart presented a paper on 
this curious subject to the Royal Academy of Medicine of Belgium. We gather 
the following as to its contents from the report of M. Delahaye. Inquiries on 
this point have usually been left to magistrates, although it is strictly a subject 
(but neglected) belonging to the medical jurist. 

After some remarks on the conformation of the plantar surface, covered either 
with a shoe or boot, and on the mechanism of walking in man, and the applica- 
tion of the foot to the ground, M. Mascart asserts that, owing to various causes, 
the foot-print on the ground is generally smaller than the foot which has made 
it. If this be so, many serious errors must have been made formerly, since the 
prevailing opinion is, that they should exactly correspond. 

The author ascribes this shortening principally to one of three causes : the con- 
sistence of the soil to which the foot is applied, the shape of the foot, or of the 
boot or shoe covering it, or lastly, the manner in which the foot was placed in 
walking. He enters into details, satisfactorily illustrating all of these. 

He allows, however, that this result is not invariable, and this may occur from 
the peculiar shape of the shoe, boot, or slipper, or from the depth to which the 
foot has gone. The reporter suggests that there may be instances in which the 
fool-print will be even larger than the foot itself. Thus, when walking on a 
light soil, the point of the foot in its forward motion may throw before it so much 
of the ground as to enlarge the front of the point. The foot, in walking, is not 
applied perpendicularly, but from behind, forwards or downwards. Hence, a 



264 Progress of the Medical Sciences. [July 

certain quantity of the ground is carried along with it, and, on measuring the 
mark, it has, under such circumstances, been ascertained, to be some lines longer 
than the sole of the boot. 

M. Mascart is continuing his investigations of this subject. — Bulletin de V Aca- 
demie Royale de Medecine de Beige, November, 1843. 

77. Chossat on Starvation. — The experimental researches of this author obtained 
for him the gold medal for Experimental Physiology in 1841, from the Royal 
Academy of Sciences of Paris. His Memoirs, published in 1843, contains 
numerous facts and important inferences bearing on physiology, pathology, and 
therapeutics. I shall, however, confine myself to those which immediately con- 
cern the subject of legal medicine. 

M. Chossat's experiments were made on pigeons, turtle-doves, common fowls, 
guinea pigs, rabbits, and several of the cold-blooded animals, as frogs, tortoises, 
serpents, &c. 

Forty-eight warm-blooded animals of all the species were totally deprived of 
food and drink, and the first important point ascertained was the constant but 
gradual diminution of weight. If the loss of the first day be abstracted, the loss 
of weight till towards the close of life was nearly the same each day. The first 
day always exhibited a greater amount of loss, in consequence of the bowels 
evacuating the remains of the last food. All things being otherwise equal, and 
taking a period equally distant from the hour at which inanition began, the loss 
was great in proportion to the bulk of the body. Towards the end of life, an 
increased amount of diurnal loss in weight was observed — a circumstance attri- 
butable to the increased amount of alvine evacuations, or even smart diarrhoea, 
which often then occurred. 

One of the most interesting points ascertained by M. Chossat was the abso- 
lute average amount of weight lost before death took place. The average result 
of all his experiments, wliether with fat or lean animals, showed that before 
death ensued the weight of the body was reduced four-tenths of what it had 
been when they were shut up to be starved. And when this occurs death en- 
sues. But it may be modified by circumstances. Thus, if the animal be loaded 
with fat, it sometimes lives till it has lost five-tenths, or one-half, of its weight. 
Age, also, exerts a powerful modifying influence. Very young animals often die 
after losing only two-tenths of their weight, and the loss in them never exceeds 
four-tenths. 

The time which an animal, deprived of all sustenance, will live, varies much. 
In birds and mammalia, the average duration of life under starvation was nine 
days. The maximum, however, was twenty days and a half, and the minimum 
was a little more than two days. Here, again, age exerted a powerful modify- 
ing influence. In very young animals death occurred by the end of the second 
day, while, in adult animals, the average duration of life was from fifteen to 
eighteen days. It is, however, a remarkable circumstance that the longer life 
was prolonged, or to be prolonged, the less was the amount of daily loss, and 
the sooner death occurred, the more rapid was the diurnal loss of weight. 

In the case of reptiles and fishes, the experiments proved that they died when 
they had lost the same proportional amount of weight as the birds and quadru- 
peds. They lived, however, much longer, as their nutritive movement is much 
slower. In general, they lived twenty-three times as long again. 

The next series of experiments, undertaken by M. Chossat, was conducted on 
the principle of allowing a very insufficient quantity of food. For some ani- 
mals there was given a very limited supply of both food and drink; to others, 
insufficient solid food alone ; and to a third, water only. 

In the first series it was singular to remark, that, when they died, their loss 
of weight was found to be very nearly the same as if they had been totally de- 
prived of food. The duration of life was, however, nearly double. 

A supply of water seemed to prolong life in reptiles, and somewhat length- 
ened it in quadrupeds, but had no influence on that of birds. The water, how- 



1844,] MedicalJunsprudence and Toxicology, 265 

ever, must be voluntarily taken, since, if forced to swallow a quantity equal to 
their daily loss of weight, their lives were shortened. 

As animals kifled by starvation thus lose four-tenths of their weight, it be- 
came a matter of importance to ascertain what organs of the body had been 
chiefly attacked to supply this loss. The fat of course first disappears, but this 
is not an essential organ. It is the muscular system, and the heart in particular, 
which bears almost the whole loss. Hence, a softened state of the muscular 
system. The nervous system appeared to have lost none of its original volume 
or weight, though every other organ of the body was reduced both in volume or 
weight. 

The animal heat falls rapidly in animals that are starved, and death occnrs in 
warm-blooded animals when the temperature falls as low as 76° 81 Fahrenheit. 
This is the temperature at which animals die which are plunged in refrigerant 
mixtures, and we may, therefore, infer that death ensues in consequence of the 
cooling of the body below what is sufficient for the purpose of life. 

Symptoms of Starvation. — The animal remains calm from the beginning of the 
experiment till the half of the period which they live, or nearly the whole period 
is expired. After this, they become more or less agitated; and this state con- 
tinues as long as the animal heat keeps tolerably high. On the last day, they 
fall into a state of stupor, attended with a rapidly increasing weakness. The 
animal shakes when it stands, and seems giddy; the feet are cold and livid, and 
contracted like a ball. The respiration becomes more and more feeble and slow ; 
the sensibility diminishes ; the pupil of the eye dilates, and the animal dies, 
sometimes tranquilly, sometimes after a few spasms, or convulsive movements 
of the wings, or opisthotonos of the body. 

The feculent discharges were, as already stated, copious on the first day, being 
the remains of the food previously taken, but were small in quantity afterwards. 
During the last three days of life, however, they augmented in quantity, and pre- 
sented the appearance of colliquative diarrhoea. The weight of these feculent 
discharges, was intimately connected with the diurnal loss of weight, and with 
the exception of the age, nothing appeared to possess a greater influence on the 
probable duration of life than the nature and quantity of this discharge ; the 
duration of life and the quantity evacuated were always in the inverse ratio of 
one another. 

The cerebral functions seem to remain entire till towards the end of life. 

As M. Chossat's experiments led him to conclude that death eventually occurs 
from the cooling of the body below what is necessary for life, he was also in- 
duced to inquire whether an animal, just expiring, could be brought back to life 
and strength, if it were plunged into an elevated temperature. The result 
was a favourable one. When placed in a heated stove, the animals gradually, 
but slowly revived. The appetite returned, but digestion did not take place 
unless the temperature was kept up at its elevated point. This last, however, 
gradually regained its power, and thus the natural animal heat was restored. 
There were, however, exceptions to this, the animal dying, notwithstanding his 
partial recovery, after successive attacks of convulsions. — Condensed from the 
Edin. Med. and Surg. Journ., No. 158, and Annates D' Hygiene, No. GO. 

T. R. B. 

78. Sudden death from a Mechanical Cause, — The following case is valuable as 
show ing the necessity of a medico-legal investigation in every instance of sud- 
den death. 

Dr. Jackson, of Leith, was sent for at 3 A.M., to visit a person who was said 
to be either dead or in a fit. He found him dead. The countenance was pale, 
with a haggard expression, and the pupils were dilated. On looking into the 
mouth, a small quantity of matter, evidently ejected from the stomach, was seen 
lying on the tongue. 

The deceased had been very intemperate. He had dined the day previous, 
on boiled potatoes, with broth, and in the afternoon, drank a quantity of over- 
proof spirits, and which indeed was considered to be the cause of his death. In 
No. XV.— .July, 1844. 23 



266 Progress of the Medical Sciences. \J^^y 

the evening-, he was brought home very drunk. He vomited a good deal, and 
was put to bed by his brothers and mother. The latter awakening during the 
night, rose to see how he was, and found him in such a state ^s to send for the 
physician. 

Dr. Jackson was naturally led to suppose that either excessive intoxication, 
or apoplexy had been the cause of this sudden death. And on examination, the 
brain was found congested — so also the lungs — while the left side of the heart 
was contracted and empty, and its right dilated and full of dark fluid blood. 
There was, however, no marked cause for these appearances yet observed, until 
he proceeded to open the trachea. Here a piece of potato skin was found, en- 
tangled between the folds of the thyro-arytenoid ligaments and completely closing 
the rima glottidis. It had evidently acted as a valve, and thus caused suffoca- 
tion. 

This substance was probably brought up in the act of vomiting, and being of 
a light nature, was drawn into its present position, from which the deceased was 
not able, in consequence of his deep intoxication, to cough it up. 

Dr. Jackson justly observes, that if the person had been found dead in a house 
of ill fame, or had been previously quarrelling, suspicion might unjustly have 
fallen on innocent individuals. — Edin. Med. aitd Surg. Journ., April, 1844. 

T. R. B. 

79. Corpora Lutea. — The Edinburgh Medical and Surgical Journal, after ana- 
lyzing the observations of M. Raciborski on the periodical deposition of ova^ by 
women'' and the females of the mammalia^ thus sums up their results, and which, 
if correct, settles a question of very great magnitude in forensic medicine. 
"They (the cases given) fully bear out M. Raciborski in the view he had adopt- 
ed, viz., that in uniparous animals one ovum, and in multiparous animals several 
ova, are developed every time the animal comes into heat, and are thrown off 
independently altogether of the animal having access to the male ; that the same 
occurs in women, every time they menstruate ; that Graafian vesicles, therefore, 
are to be found in the ovary, whenever the animal is at the rutting season, or 
when women are menstruating, and that corpora lutea follow the bursting of the 
vesicles in every case. Neither the presence of corpora lutea, nor of (Graafian 
vesicles in the ovaries, are therefore any proof of the loss of virginity, or nf a female 
having had access to the male. Nothing but the presence of a fecundated ovum in 
the uterus can prove this.^^ — Ibid. 

80. Medico-legal Inquiry into the Diagnostic character of Ecchymoses. By Dr. 
Henry Bayard. {Jinnales Lf Hy giene, October, 1843.) In a long and valuable 
paper. Dr. Bayard, by an extensive reference to facts, endeavours to point out 
the distinguishing or diagnostic characters of the different kinds of ecchymoses 
or effusions of blood which occur in the human body — as well those which 
result from injuries (blows or poisons) as those arising from the state of the 
system. His conclusions, in which the characters of the one form are con- 
trasted with those of the other, are as follows. 

Traumatic ecchymoses, 1. Are the result of external causes. 2. They have at 
times a considerable extent, but generally exist in only one place. 3. Tume- 
faction, more or less apparent, often elastic and presenting a shining appearance, 
attends them, and a change in the colouration of the part soon takes place. At 
first the colour is livid or lead coloured, but it becomes violet or reddish. 4. In 
these ecchymoses the colouration is most intense at the centre. 5. The tempe- 
rature of the part is above that of the surrounding surface. 6. The blood gene- 
rally coagulates, but when effused in large quantity it does not coagulate, but 
gives rise to the formation of abscesses. 7. The seat of the effusion is quite 
indeterminate and accidental. 8. The capillary vessels are ruptured; the 
colouration of the vessels disappears on maceration. 9. The coincidence of 
illness or general disorder of the system is quite accidental. 10. The hemor- 
rhage of the mucous membranes is the result of accidental causes. 

Spontaneous ecchymoses^ 1. Are the effect of internal causes. 2. Are limited to 



1844.] MedicalJurisprudence and Toxicology, 267 

a small space, but then the spots are numerous. 3. Generally exist without 
any tumefaction; the blackish tint chanjjes little and only slowly disappears. 
The colour is generally brown, or like the lees of wine. 4. In these ecchy- 
moses the shade of colour is uniform over all the spot. 5. The temperature is 
the same as that of the sound parts. 6. Blood is only effused in small quantity 
and remains fluid. 7. General ecchymoses are observed over the whole body; 
local ecchymoses generally occur in the limbs, and especially on the lower 
extremities. 8. The capillary vessels are not ruptured, in general; the coloura- 
tion of the tissue does not disappear on maceration. 9. A disease, or general 
illness, or organic disease, almost always precedes, and is the cause of sponta- 
neous ecchymoses. 10. The mucous membranes are frequently the seat of 
spontaneous hemorrhages. — Ibid. 

81. Poisoning by Lead. By MM. Flandin and Danger. — {Comptes Rendus.) 
In a memoir read before the Academy of Sciences, these observers arrive at the 
following conclusions. 1. There exists no lead in the human body in the 
healthy state. 2. The symptoms, and particularly the cadaveric lesions pro- 
duced by poisoning from lead, are quite characteristic. 3. If death follows 
immediately, lead will be found in the body as surely as arsenic or copper. It 
should be particularly sought for in the digestive canal, the liver, the spleen, 
the renal apparatus, and the lungs. It is not detected in the blood, the heart, 
the brain, the muscles, nor in the bones. 4. The best process for its detection, 
is, with ja very slight modification, the same as for the detection of arsenic, 
antimony and copper. It consists in carbonizing the animal matter by sulphuric 
acid, heating the carbon to redness, treating it by hydrochloric acid, then by 
water, in order to employ on the liquid the reagents proper for characterizing 
lead. 5. Unlike copper, the lead absorbed is eliminated by the renal secretion. 
6. The absorption of poisons is particularly induced by the vense portarum, 
which explains why they are found in such large quantity, and some of them 
almost exclusively in the lower. 7. When the poisoning has been produced by 
the skin, the absorption or transmission of them is made principally by the super- 
ficial subcutaneous and submucous blood-vessels and lymphatics; having passed 
in particular into the digestive tube, by a kind of perceptible perspiration, the 
poison is rejected by the vomitings or by the stools, or else it is taken up by the 
system from the venaj portarum, absolutely as if it had been introduced by the 
stomach. Hence the utility of prescribing to those working in lead, vi'ho suffer 
from it, acid, saponaceous or sulphurous lotions, and baths. 8. In medico-legal 
investigations, certain organs should be exclusively operated on, and not all the 
parts of the body indifferently. The liver should be selected, and in ordinary 
cases the tenth part of this organ (500 grammes, about one pound) is sufficient. 
^Chemist, May, 1844. 

82. Trial for Infanticide. — The prisoner, Ann Walters, an unmarried woman, 
had taken a place to go by a stage-wagon, on the 13th of April, 1841; she started 
by the wagon from Worcester on the evening of that day, and was in the wagon 
at about 10 o'clock on that ni^^ht, at the W^ellington Inn, which is situated on 
the Malvern Hills. It also appeared that she must have left the wagon after 
that time, as she overtook it at Ledbury. It was further proved in evidence, that 
she was delivered of a child at the road-side, between Wellington Inn and Led- 
bury, and that after the child was born, she carried it a distance of about a mile 
to the place at which the child was found dead, which was also at the road- 
side. It further appeared that this was a much frequented road, and that two 
wagon teams and several persons were on it about the time at which the child 
was left, and that a wagoner, who was passing along the road, heard the child 
cry, but instead of going to render any assistance, he went on and told some 
other persons, who went to the place where the child lay, and there found it 
dead from cold and exhaustion. The body of the child was quite naked, and 
the navel siring was not lied. It also was proved, that the prisoner had 



?6i Progress of the Medical Sciences, [July 

arranged with a woman to be confined in her house, and that she should be paid 
3s. Qd, a week to take care of the child. 

•Tudg-e CoUman, (in summing' up.) If a party do any act with regard to a 
human being, helpless and unable io provide for itself, which must necessarily 
lead to its death, the crime amounts to murder. But if the circumstances 
are not such, that the party must have been aware that the result would be 
death, that would reduce the offence to the crime of manslaughter, provided the 
death was occasioned by an unlawful act, but not such as to imply a malicious 
mind. There have been cases where it has been held, that persons leaving a 
child exposed, and without any assistance, and under circumstances where no 
assistance was likely to be rendered, and thereby causing the death of the child, 
were guilty of murder. It will be for you, in the present case, to consider whe- 
ther the prisoner left the child in such a situation that to ail reasonable appre- 
hension, she must have been aware the child must die, or whether there were 
circumstances that would make it likely, that the child would be found by some 
one else, and its life preserved, because then the offence of the prisoner would 
be manslaughter only. It is impossible to say that the offence of the prisoner 
can be less than manslaughter. It is for you to consider whether, under all the 
circumstances, this child was left in such a situation, that there was a reason- 
able expectation, that it would be taken up by some one else and preserved. Sup- 
pose a person leaves a child at the door of a gentleman, where it is likely to be 
taken into the house almost immediately, it would be too much to say, that if 
death ensued, it would be murder; the probability there would be so great, 
almost amounting to a certainty, that the child would be found and taken care 
of. If, on the other hand, it were left on an unfrequented place, a barren heath, 
for instance, what inference can be drawn, but that the party left it there, in 
order that it might die. This is a sort of intermediate case, because the child 
is exposed on a public road, where persons not only might pass, but were pass- 
ing at the time, and you will, therefore, consider, whether the prisoner had 
reasonable ground for believing that the child would be found and preserved. 
Verdict — Guilty of manslaughter. — /. Carrington ^ Marchani's Nisi Prius 
Reports, p. 164. T. R. B. 

83. The Queen v. Trilloe — Infanticide. — There was strong evidence to prove 
that the child had been born alive, and that the prisoner had strangled it by fas- 
tening a handkerchief or some such thing round its throat, but it was clearly 
proved by Mr. Wood, the surgeon, who examined the body of the child, that it 
nmust have been strangled before it had been separated from the mother by the 
severance of the umbilical cord, and it was further stated by Mr. Wood, that a 
child has, after breathing fully, an independent circulation of its own, even 
while still attached to the mother by the umbilical cord, and that, in his judg- 
ment, the child had breathed fully after it had been wholly produced, and had, 
therefore, an independent circulation of its own, before and at the time it was 
strangled, and was then in a state to carry on a separate existence. 

Judge Erskine, in summing up, said, "If you are satisfied that this child had 
been wholly produced from the body of the prisoner alive, and that the prisoner 
wilfully, and of her malice aforethought, strangled the child after it had been so 
produced and while it was alive, and while it had, according to the evidence of 
the surgeon, an independent circulation of its own, I am of opinion that the 
charge in the second and third counts of the indictment is made out against the 
prisoner, although the child at the time it was so strangled, still remained 
attached to the mother by the navel string. Verdict — Guilty. The case was 
reserved by the judge for the opinion of the fifteen judges, who held the convic- 
tion right.— /6ia!., p. G50. T. R. B. 



1844.] 269 



AMERICAN INTELLIGENCE. 

ORIGINAL COMMUNICATION. 

Case of Suspected Infanticide. By J. H. Thompson, M. D., of Salem, 
N. J. — As the true value of the Hydrastalic Test is " adhuc sub judice," 
having on the one hand been gravely pronounced by judicial lips to be 
"a vulgar error," a sentence very nearly, if not quite, in accordance with 
the opinions of some members of the medical profession, and on the other, 
by many of the distinguished ornaments of that same profession, considered 
under certain limitations an infallible guide in determining a most important 
medico-legal question, the following case is related with the single view 
of placing upon record one more observation in addition to those already 
made. 

Hannah , a white woman, a domestic residing in the family of Mr. 

B , was believed to be pregnant, but positively denied the charge. 

She was married and had three children, but had not for several years 
lived with her husband, who resided in another part of the state. She had 
always borne a good character — had never been fond of company, rather 
avoided than sought it. She saw her husband sometime in October, 1842, 
not having seen him before for a long time, nor did she see him afterward. 
She slept one night in the same house with him, but not in the same room, 
and it was positively affirmed that he did not see her except in the pre- 
sence of a third person. About the same period, through the persuasion 
of an associate, for a short time she was led into company of a question- 
able character, and was known to have been accompanied home on several 
occasions, by a young man, who, however, did not remain with her. She 
was repeatedly asked if she had made any preparation for the birth of her 
child; she constantly denied her pregnancy, and of course the necessity for 
any preparation. At daylight, on the morning of July 20th, 1843, Mrs. 

B discovered that Hannah had been delivered. She had left her own 

room and gone to an unoccupied one in a distant part of the house. When 
asked for the child she said it was still-born, and tljat she had taken it into 
the garden, where in fact it was found, having been concealed under some 
bushes. 

These facts having been made known to the coroner, a jury was sum- 
moned, and T was requested to conduct the post-mortem examination. 
Accompanied by Dr. Tuft, I proceeded to the place. We found the child 
to be a white male, of the average size; the nails were perfectly formed; the 
head was covered with hair; it was plump, and had, in short, every 
appearance of maturity. It was nineteen inches in length, and weighed 
six lbs. ten ounces. No marks of violence were found upon the body. 
The cord had been cut about five inches from the umbilicus — no ligature 
had been applied. The surface of the body was moderately pale. There 
was slight lividity of the lips and f\ice. The chest, on external inspection, 
was rounded and evidently of full size. On opening the thorax, the lungs 
were seen nearly filling the cavity of the chest. They were of a general 
rosaceous appearance. After being very carefully removed, together with 
the heart and thymus gland, they were placed in fresh spring water of the 
ordinary temperature, and floated with great buoyancy. They were sepa- 
rated, and the right lung was cut into a number of pieces; on being returned 

23* 



270 American Intelligence. [July 

to the water they all floated as buoyantly as before. Although there was 
not the slightest appearance of putrefaction, (the birth had probably taken 
place eight or ten hours before the examination ; the weather beside was 
cool for the season, the thermometer, at noon, in my office, being 72° F.,) 
and no probability that artilicial inflation had been attempted, I placed ofte 
of the pieces in a strong linen cloth, and compressed it with all the force I 
was capable of exerting. On throwing this again into the water it did not 
appear in the slightest degree to have lost its buoyancy. The lungs 
appeared to be in every respect perfectly healthy — they crepitated when 
cut. The relative weight of body and lungs was 49.5, which is consider- 
ably greater than Ploucquets average estimate, and is also greater than that 
given by Dr. Beck. There was, however, a slight degree of inaccuracy 
in weighing both the body and lungs, which doubtless affected the result. 
The ductus arteriosus was not larger than one of the branches of the pul- 
monary arter)^. It was contracted in the middle^ presenting somewhat of 
an hour-glass appearance. 

As the jury had become exceedingly impatient at their detention, the 
dissection was not continued. The state of the ductus venosus, foramen 
ovale, and intestinal canal, however desirable it would have been to examine 
them, could not, I suppose, have thrown any- additional light upon thB 
subject, since it is well known that the changes from which an inference 
could be drawn, do not take place until some time afterbirth; and it is 
certain that this child, if born alive, had been permitted to live but a very 
short time. Had not enough been ascertained to justify the conclusion to 
which we come, that the child had not only been born alive, but that respi- 
ration had been perfectly established? The manner of its death was not 
so evident. If it had died from hemorrhage, would not the surface have 
been blanched and the blood-vessels empty? Writers on medical juris- 
prudence answer in the affirmative, and yet in this case the colour was not 
very different from natural, and the blood-vessels were full — certainly more 
than three ounces could have been collected from the cavity of the thorax 
alone. My own belief is, that the woman cut the funis and immediately 
afterward smothered her child in the clothes in which it was found enve- 
loped, thus adding suffocation to hemorrhage, and so making "assurance 
doubly sure." The appearance of the face strengthens this supposition. 
The verdict of the jury was that the child was born alive, and that its death 
was owing to neglect on the part of the mother. Here the matter rested — 
she was not tried for the offence. 

Much might be said upon the subject of this indifference to the life of a 
child, did time and space permit. Since the above case occurred, I have 
seen an instance in which the child cried after the head was born, and 
detention was caused by the shoulders — the birth was completed in time to 
preserve the child. I have also been informed of a case, in which the 
child was suddenly expelled while the mother was standing on the floor. 
The funis was ruptured about four inches from the body — there was no 
hemorrhage, nor was the child at all injured by the fall. 



DOMESTIC SUMMARY. 

Angular Anchylosis of the Knee-Joint^ treated by Dr. J. R. Barton's method. 
— Dr. A. R. Kilpatrick reports in the Western Journal of Med. and Surg., June 
1844, a case of anchylosis successfully treated by Dr. Platt Burr of Cheney- 
ville, La., by Dr. Barton's method. 



1844.] American Intelligence. 271 

The subject of the case was a negro man 40 years of age, of slout frame, and 
good general health, who, while engaged, on the- 12th December, 1840, in 
hewing a log-, accidentally let the broad axe slip, and the corner of it struck the 
left knee with considerable force, on the inner side, and penetrated the side of 
the head of the tibia close to the patella. The wound was not more than an 
inch long, and soon healed up, although there was slight pain in the part. By 
exposure and active exercise, the knee was swollen rapidly to a very large size, 
and that, together with the pain, disabled him for work and forced him to take 
his bed. 

The measures adopted for checking the inflammation were unsuccessful, and 
the whole limb became enormously enlarged, suppuration came on, and a 
great quantity of pus was discharged at three several openings, above and 
below the knee. The purulent discharge ceased, the limb was reduced in size, 
the muscles were flaccid, and the skin was loose, dry and crusty, so much so 
that when rubbed or thumped it emitted a sound like that of coarse brown paper 
or dry raw-hide. The knee still continued unnaturally larg-e, and the skin on it 
was tight and glossy. As he suffered less pain when the leg- was flexed, he 
was permitted to keep it in that position so long that it became fixed ; the syno- 
vial fluid and membranes were destroyed, the femur, tibia and patella all united 
firmly together as if they were a continuation of one bone, and from the firm 
adhesion which had taken place, considerable force would have been required to 
disunite them. When he was seated, no one could perceive that any deformity 
existed ; but on his assuminor the erect position, his leg and foot projected back- 
wards at a right angle with the other leg. 

Dr. Burr being consulted, he advised an operation, and the patient consent- 
ing, Dr. B. operated on the 8th December, 1841, one year after the injury. 

The patient was placed on a table with his legs hanging down over the end, 
his body and arras being held by assistants. " The first incision was made by 
commencing at a point opposite to the upper and anterior margin of the external 
condyle of the femur, and passing obliquely upwards across the front of the 
thigh, terminated on the inner side. The second incision commenced also 
on the outer side, about three inches above the first, and passing obliquely 
downwards across the front of the thigh, terminated at the point of the other 
incision, thereby forming an acute angle. The integuments, the extensor mus- 
cles, part of the vastus externus, and internus and the crureus were divided by 
these incisions. The triangular flap was then dissected up from the femur 
close to the condyles, and the soft parts on either side were pressed down out 
of the way, so as to admit of the free use of the saw. The only knife emploj^ed 
in all the operation was the common scalpel. 

"The flap then being turned up and held out of the way, a common amputating 
saw was used, and by inclining it, a wedge-shaped piece of the femur was taken 
out, about two and a quarter inches at the base, and three lines at the apex. 
The femur was not completely divided by the saw, as was suggested by Dr. 
Barton, but about three lines were left undivided, which was fractured by forci- 
bly drawing the leg back, and the spiculae thereby formed answered the purpose 
admirably of keeping the extremities of the bone in their proper place; and, 
moreover, the danger of injuring the popliteal artery was thereby avoided. 

"The time required for the operation was about five minutes. There were 
three small arteries divided which required ligatures; when they were secured 
the flap was returned to its place, secured by a few sutures, the ends of the 
ligatures were brought out and fixed, and adhesive strips and light compress 
and bandages completed the dressing. 

" Before moving the patient from the table, the limb was placed at the same 
angle of flexion it was at before the operation, on a double-inclined plane simi- 
lar to Amesbury's apparatus, with a movable cross piece to regulate and fix its 
angularity, and a foot piece with a shoe attached to it. The plane was rendered 
comfortable by long bags of carded cotton, suited to the shape of the parts 
and so adjusted as to prevent pressure or friction upon the popliteal region. 
The limb was kept in that angular position for some weeks, until it was thought 
the spiculae and asperities of the bone were either absorbed or covered by depo- 



272 Jlmerican Intelligence. [July 

site. The sutures and ligatures of the arteries were properly attended to and 
removed. Adhesion of ihe soft parts progressed rapidly and regularly to com- 
plete re-nnion with little pain or trouble. 

" By means of the brace on the apparatus the limb was gradually straightened 
until brought very nearly straight, but agreeable to the suggestion of Dr. Bar- 
ton, a very slight angularity was maintained intentionally, in order to prevent 
his heel, in walking, from striking against any obstacle or inequality whicK 
might be in the way. The double-inclined plane was then thrown aside, and 
the limb placed in the ordinary straight box used in common fractures, where 
it was kept for better than three months, at the expiration of which time he 
allowed to move about on a crutch, as the bones had knitted together pretty well." 

In the month of June, 1842, he could walk about on his leg without the use 
of a staff, and went to work. But on the i5lh of July, of the same year, in 
attempting to mount a ladder he missed his footing, and in the fall broke his leg 
again at the point of operation. As he had complained of his foot hurting in the 
instep, at the metatarsus and toes, especially when he walked much, and when 
standing on logs chojtping, when it was reset the last time, it was placed in the 
straight box without any angularity, being quite straight. No bad results fol- 
lov/ed this fracture, and in less than two months he was able to be up and 
about again, and could walk very well without crutch or staff. 

Dr. Kilpatrick says that he saw the patient on the 15th April, 1844, busily 
engaged in spading up the garden. He told Dr. K. that he could hoe and chop 
with as much ease as ever he did; and ploughing was not irksome to him. 

Self-propelling Power of the Bloods — Dr. Horace Green made the following 
communication on this subject to the New York Medical and Surgical Society. 

"Opposite opinions," remarked Dr. G., "are still entertained by physiolo- 
gists on this subject. Treviranus, Oesterreicher, Woltf, and several other 
microscopists, declare, that 'the blood is endued with the power of self-pro- 
pulsion,' which they suppose to be exerted in the capillaries, during life, inde- 
pendently of the heart's action, and to continue after the latter has ceased; 
while, on the other hand, Baer, Wedemeyer, and, more recently, MiiUer, deny 
as positively the existence of a self-propelling power in the blood. 

" Flaving been engaged of late in making some microscopic observations 
upon the blood and other animal fluids, this subject, said Dr. Green, among 
others, had engaged his attention; and he supposed it might not be uninterest- 
ing to the Society to hear the result of some experiments which have been di- 
rected to this point. 

" MiiUer, who denies the existence of a power in the blood, independent of 
the heart's action, allows that there are two conditions under which the blood 
in the capillaries of a transparent part, separated from the body, may still be 
seen in motion by means of the microscope. One, where the blood continues 
to flow from divided vessels — the escape of the blood from the openings of these 
divided trunks imparting or causing a motion of the blood in the minute vessels 
toward the openings in the larger ones. The second condition under which 
motion is perceptible, is, when the direct rays of the sun are allowed to fall on 
a moist part separated from the body. The surface of the part thus becomes 
dry and wrinkled, and this constriction causes a rapid emptying of the capillary 
vessels, which, tocrether with the effect of illumination by the direct rays of the 
sun, produces a flickering appearance ; and in this way he imagines opposing 
observers have been deceived. Dr. G. has himself observed, in numerous 
instances, motion of the blood in capillary vessels, active and continued, inde- 
pendent of the heart's action, when the above condition of things could not have 
existed. 

" By placing under the field of the microscope the most transparent part of 
Jhe web of the foot of a very small frog. Dr. G. has observed many capillary 
vessels so minute as to be capable of admitting only a single fill of red globules. 
These globules may often be seen running different directions in parallel ves- 
sels; and, not unfrequenlly, single globules, and sometimes two or three toge- 
ther, may be observed, separated apparently at a considerable distance from any 



1844.] American Intelligence. 273 

others, and yet, moving on slowly in some instances, and rapidly in others, 
independent of any vis a tergo power; so that, as the contractile power of the 
capillaries (except so far as regards the natural elasticity of their coats), is 
denied by these physiologists, the motion of these single globules must be 
independent of the heart's action, and dependent on an inherent power of their 
own. Not only this, but not unfrequently in watching the current of globules 
in these minute vessels. Dr. G..says that he has observed them to be sud- 
denly arrested, and then to recede for some distance along the course of the 
vessel. This phenomena is accounted for by Miiller, on the supposition that 
the vessels may have been compressed by slight motions of the frog. This 
could not have been the case, said Dr. G., in one instance which he recently 
noticed, where a capillary vessel was seen to pass directly through the centre of 
a pigment cell, in a frog's foot. In this vessel, red globules were seen repeat- 
edly to run in different directions in the same vessel, and to pass each other in 
the centre of the cell. If the motion of the blood in the capillaries is entirely 
dependent upon the heart's action, how can we account for this power being 
exerted in different directions in the same vessel? 

" Other evidences, said Dr. G., of this inherent power of the blood have been 
observed. Having removed an elongated uvula, a few days since, the most 
transparent portion of the truncated part was placed under the field of the micro- 
scope. Upwards of half an hour after the part was exercised, the blood was 
seen to move slowly along the capillary vessels; and yet, the precaution was 
taken to keep the piece moistened, so that the vessels might not contract from 
drying. 

''Dr. Carpenter designates this motive force of the blood, the 'capillary 
power' of this fluid ; and he believes that we are furnished with all the proof 
that can be needed of the existence, even in the highest animals, of a capillary 
power, which, though usually subordinate to the heart's action, is sufficiently 
strong to maintain ihe circulation by itself, when the power of the central organ 
is diminished. But the term which he employs, capillary power, is evidently 
inappropriate, inasmuch as this power remains in the globules after they are 
withdrawn from the capillaries. By placing a drop of fresh arterial blood upon 
the glass, and examining it with the microscope, the globules will be seen to be 
in active motion for several minutes after they are withdrawn from the artery; 
and in some instances, Dr. G. says that he has observed them to form currents, 
and to circulate regularly, for a short distance, as if they were still in the capil- 
lary vessels. The same vital movements may be observed in a drop of the 
menstrual fluid, if examined immediately after its escape from the vagina. 

" These experiments may tend in some measure to establish the theory that the 
blood is endued with a vital power of self-propulsion." — N. York Journ. of Med.j 
May, 1844. 

Epidemic Erysipelas. — Dr. D. Meeker, in a communication in the Illinois 
Medical and Surgical .Journal, (.Tune 1844), states that the Epidemic Erysipelas 
made its appearance at Michigan City, Laporte co., la., in December, 1843, 
where it still prevails, though with diminished violence. Of sixty cases, one 
half have been fatal. "The commencement of the disease," he says, "was 
generally characterized by lassitude, cold or chilly sensations ; in severe attacks, 
the cold stage lasting for some time, followed by high arterial action. In many 
cases, some swelling of the tonsillary glands, with an efflorescent or inflamed 
appearance of the mucous membrane of the fauces existed, with a dryness of the 
tongue, which was covered with a dark brown coat, neuralgic pains in the situa- 
tion of the lymphatic glands of the neck, axilla, and frequently of the lower 
extremities. The inflammation did not make its appearance upon the skin in 
many cases until the second or third day, and sometimes not until a later period. 
In other cases, the internal organs became inflamed, without its making its 
appearance upon the surface at all. 

" It seemed t